Sources of Drug Information and the Rate of Reading Patient Information Leaflets by Medical Sciences Students

Background and aims: Patient information leaflets (PILs) are the best form of written information transfer. The aim of this study was to investigate the sources of drug information and the reading rate of PILs among medical sciences students. Methods: Three hundred students were entered in this cross-sectional study via simple random sampling at the Faculty of Paramedical, Nursing and Midwifery of Guilan University of Medical Sciences in 2018. Results: The participants considered the physician as the most reliable source for receiving drug information. Pharmacists, PILs, and the Internet were mentioned as the next sources, respectively. About 15.3% of people always read PILs. Students used PILs along with other sources of drug information. Conclusion: The type of medication and the individuals’ need for the type of information, along with the structure and presentation of the materials in the PILs, are all contributing factors.


Introduction
During the treatment process, knowing the drug and controlling how it is used can be done via oral or written instructions. In using oral instructions, there is the possibility that information is forgotten, not well understood by people, or there will not be enough time to convey information. 1,2 Therefore, patients today seek to receive written information. 3 Although patient information leaflets (PILs) cannot replace communication with a physician, 1 they are the best tool for educating patients so that they can use their medications in the best way and benefit from the treatment. 4 Since receiving information from other sources and physical characteristics of drug leaflets can affect the rate of reading PILs, it has been tried in this study to investigate other sources to receive drug information and some effective features in studying PILs. The purpose of this study was to determine the receiving of drug information sources and the rate of reading PILs among paramedical students. The results of this study will be used for improvement in the practice of drug leaflets, and ultimately increase in the rate of reading PILs in the community.

Methods
This cross-sectional study was performed in the Faculty of Paramedical, Nursing and Midwifery of Guilan University of Medical Sciences in 2018. The total number of students was about 1000 in all fields. According to Morgan table and taking into account the accepted error of 0.05, the sample size was 278 students, which was determined to be approximately 300 students with 10% drop. Noninternship undergraduate students who were present in the faculty entered the study voluntarily and randomly. Based on the opinions of expert group, the Lawshe table was used and CVI = 98% and CVR <62% were determined. The Cronbach's alpha coefficient of 70% was determined by questionnaire given to 30 students before the study.

Results
In this study, the average age of students was 21 years. Nearly, 22% of the statistical population in this study were male and 78% female, and 19.4% were anesthesiologists, 20% operating room specialists, 19% laboratory scientists, 10.3% radiologists, 14% midwives, and 17.3% nurses in terms of their field of study. About 9% of participants reported that they didn't need supplementary information before taking the drugs. Nearly, 7.3% of participants received supplementary information only for expensive and special drugs.
Only 15.3% of people always read PILs and did not take the medication without reading them (Group A, Table 1). Nearly, 7.3% of students never read the brochures and the reading rate was lower in 77.4% of the rest of the people (Group B, Table 1). The reasons for these people for not caring about reading PILs among 40% was lack of time and interest, and 41.3% reported that the information taking from physicians and pharmacists is enough. The main purpose of reading PILs in 62.7% of the subjects was to obtain more information and 52.3% of the statistical population reported the Internet as an alternative source of PILs. Table 2 shows the influenceability of reading of PILs from the physical properties and information mentioned in the brochures in the form of two-choice questions (yes-no).
In this study, leaflets of cardiovascular and neuropsychiatric drugs were decided as the most important  ones for the study. About 51.7% of the subjects gave full marks for the importance of reading these two types of leaflets, while the leaflet of non-narcotic pain relievers was selected with the lowest score (4.86) (Figure 1). Participants showed ways to obtain drug information by scoring. The physician was considered the most suitable source for receiving drug information, with people having a history of taking drugs in the next placements of scoring the source of obtaining drug information (Figure 2).

Discussion
According to the results of this study, the majority of students obtained their drug information through PILs and other sources before taking the drug. The reason for reading the PILs was to obtain more information about the drug used, which is similar to the previous study .5,6 Educated people are usually looking for more medical information to be able to get involved in their own decisions.
In this study, 7.3% of people had never read the PILs. In a review study, well-educated patients were able to take their medications correctly in addition to meeting their medical needs. This ability has been more limited in less literate people. 7 In a study in Iran, Nader et al. showed that in a society with 26% of people with university education, 31% of people never read PILs. 2 Because the subjects all had university education, the level of reading PILs among students in this study was lower than expected compared to Nader et al.'s study.
In the present study, 45% of the subjects developed anxiety after studying the side effects. In a study, some participants believed that only serious side effects should be considered and unlikely sections should be omitted for this section, because the writings about the side effects of medications raised doubts about the continued use of them. 1 Using qualitative words and not specifying the exact possibility of side effects can lead to misinterpretation of the side effects of the drugs. 8,9 One of the purposes of PILs is to provide the patients with accurate information. Patients are reluctant to receive vague information that leads to doubts about their continued treatment. 10 This section should be further explored while being important in PILs.
According to the opinions of the students in this research, the layout of PILs, the difference in the font of the writings, and their preparation in non-native languages can affect their reading rate. In previous studies, being long and short, the presence of a large volume of content, and fine font in the writing of PILs had a deterrent effect on the study. 1,10,11 Because the comprehensibility and usefulness of the information written in the PILs is very important for patients, 6,12 so when the information is written in such a way that patients have the ability to read and easily understand the material, they are encouraged to read them more. As a result, patients' knowledge of their medication increases 4 and patients are encouraged to complete the treatment process. 12,13 In the present study, the information contained in the PILs was comprehensible to most people and this matter affected their reading rate. This is probably because the subjects were studying in medical sciences, and the information in the PILs was more comprehensible than that in the studies in which the educated and the uneducated were examined at the same time.
The subjects in this study determined doctors and pharmacists as the most important source of information. This is similar to the results of previous studies. 5,6,14 Herber et al showed that PILs could not replace a physician's oral explanation, and many people preferred to be told the contents of the PILs orally by a physician. 1 According to Dickinson et al., individuals tend to seek general information from PILs and specific information about themselves from physicians. 10 Also, the emphasis of pharmacists and physicians on reading PILs can affect patients' attention to their reading. 10,15 Our assessment is that due to having accurate knowledge of the disease and the relevance of their specialized knowledge, physicians and pharmacists are respectively important and accurate sources of information, but due to lack of easy access to them or lack of necessary advice from them, individuals replace other sources for obtaining information.
In the absence of PILs, the Internet was an alternative source of pharmaceutical information. The choice of the Internet as a source of pharmaceutical information is probably due to having sufficient knowledge to use it, the large number of virtual pages containing pharmaceutical information such as sites and weblogs, greater ease of access to information through it compared to other sources of pharmaceutical information, and a significant expansion of Internet access tools in Iran.

Limitations of the study
The narrow range of age among participants was the limitation of this study.

Conclusion
Getting information from a doctor, pharmacist, and the Internet was an influential factor in reading the PILs. The physical appearance of the PILs also affects the reading rate of the students.