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Posted on Authorea 28 Aug 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission.

— https://doi.org/10.22541/au.159862973.35431637 — This a preprint and has not been peer reviewed. Data may be preliminary.

Treatment and perspectives of patients diagnosed with psychiatric


disorders living in rural areas in Jordan: identifying barriers and
role of pharmacists.
Eyad Qunaibi1 , Malak Afeef2 , Bayan Othman2 , Abdullah Al-zoubani2 , and Iman Basheti3
1
Jerash University
2
Affiliation not available
3
Applied Science Private University

August 28, 2020

Abstract
Introduction: Patient adherence is a cornerstone in successful management of psychiatric disorders and is affected by patient
perspectives and barriers, differing from rural to urban areas. In this perspective, pharmacists have a vital role in identifying
patients in need of help and in dealing with barriers to adherence. This paper investigates perspectives of patients diagnosed
with psychiatric disorders, living in rural areas in Jerash, Jordan, regarding their awareness about their psychiatric conditions,
including religious and cultural factors, adherence to their treatment and related barriers, with special focus on pharmacist’s
role. Methods: This cross-sectional survey study was conducted in Jordan from August to November 2019. A validated
questionnaire was administered by two pharmacists, asking patients as they were waiting in the psychiatric clinic (following
the specialists’ approval). Data were analyzed using the Statistical Package for the Social Science (SPSS). Results: Most
patients (n= 120, age 39.4±9.5, 66.7% males) reported that they always/usually adhere to their medications (71.0%), and
47.5% of them reported complete control of their symptoms after treatment. Most patients (69.2%) reported that they perceive
their psychological illness in terms of religious faith as being counted for their favor in the Hereafter, and 52.5% of them
always/usually looked at themselves positively and unaffected by the existence of their illness; with both factors correlating
significantly with better treatment adherence (p < 0.045 and p < 0.001; respectively). Barriers affecting adherence included
mainly suffering from adverse effects (31.9%) and being unconvinced that they needed a medication (23.3%). Only 14.2% of
patients reported that they refer to the pharmacist to get information about their medications. Conclusion: Most psychiatric
patients reported suboptimal control of their symptoms. Nonadherence is one reason, with barriers identified. Positive religious
and cultural perspectives are associated with better adherence, and most patients do not refer to pharmacists for medication
informatio

What is already known about this topic?


The rate of psychological disorders continues to grow globally, affecting millions of people worldwide. Alt-
hough primary healthcare teams exist in rural areas to provide services to chronically ill patients, including
those diagnosed with psychiatric disorders, barriers exist. Identifying barriers and relationship of patient
beliefs and values, and proper adherence can help in optimizing the management of patients.
What does this article add?
This paper reports the perspectives of patients diagnosed with psychiatric illnesses, living in rural areas
in Jerash, Jordan, regarding their awareness about their psychological conditions, including religious and
cultural factors, adherence to their treatment and related barriers, with special focus on pharmacist’s role.
Most psychiatric patients reported suboptimal control of their symptoms. Nonadherence is one reason, with

1
barriers identified. Positive religious and cultural perspectives are associated with better adherence, and
most patients do not refer to pharmacists for medication information.
Posted on Authorea 28 Aug 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159862973.35431637 — This a preprint and has not been peer reviewed. Data may be preliminary.

Introduction
The rate of psychological disorders continues to grow globally, affecting millions of people worldwide. To have
a deeper insight into the proportions of specific psychological conditions, it has been reported that 264 million
people suffer from depression, 45 million from bipolar disorder and 20 million from schizophrenia (1),(2). In
Jordan, the number of patients diagnosed with psychological disorders has not been published, however, it
was documented in a World Health Organization (WHO) report that there are 64 mental health outpatient
facilities in Jordan, which provide services to an estimated 305 users per 100,000 population, with the most
commonly assigned diagnosis at both outpatient facilities and mental hospitals being schizophrenia (3).
According to the WHO, Jordan has been identified as a country in need of intense support for strengthening
the mental health system (4). As is the case all around the world, in Jordan, females suffer from psychological
conditions more than males (5),(6).
With the growing burden of psychiatric disorders worldwide, creating a partnership relationship between
patients and their healthcare professionals is vital for proper management (7, 8). This can be done by taking
into consideration patients’ preferences, needs and values (7, 8). Hence, assessing patient’s beliefs and how
it affects the management of their condition would be useful (9).
Over the past years, the pharmacists’ role has developed to include numerous patient-oriented clinical services
(10). Being at the front line, pharmacists have a unique position due to their direct contact with patients (11).
Hence, pharmacists can successfully identify patients in need of help, including psychologically ill patients
hesitant to visit their specialist to get help (12-14).
In addition to their accessibility, the important role of the pharmacists in the psychological healthcare
sector was found to be acknowledged by both healthcare professionals and patients around the world (15).
Pharmacists were found to enjoy a high level of patient trust in Arab countries as well, including Jordan
(13), assisting in opportunistic screening for depression and anxiety (12).
Adherence to treatment is important for psychologically ill patients considering the young age of the popula-
tion, the high alert medications used in their management (16), the side effects of treatment and withdrawal
symptoms due to misuse. Identifying barriers and relationship of patient beliefs and values, and proper ad-
herence can help in optimizing the management of a culturally and religiously oriented group of patients
(17, 18).
Previous studies reported a positive effect of religious beliefs of Muslims on coping with mental disorders and
other distressing conditions (19-22). However, the impact of religious beliefs on the perception of psychiatric
illnesses and adherence to medications by the Muslim population has not been assessed as yet.
Culturally, perceived public mental illness stigma and self-stigma, causes a delay in active help-seeking
behavior (23). However, the size of this stigma among patients who do seek help in the relatively “closed”
rural cultures and its effect on adherence has not been evaluated.
In addition, several studies on patients with psychiatric disorders have revealed overall high rates of perceived
benefits of psychotherapeutic interventions, including a study in Amman, the capital of Jordan, which invol-
ved a sample of 100 patients who received psychosocial expert interventions (23). No previous study, however,
has evaluated the awareness and preference of psychotherapy among patients with psychiatric disorders in
rural areas.
Although primary healthcare teams exist in rural areas to provide services to chronically ill patients, including
those diagnosed with psychiatric disorders, barriers exist (15, 24). No previous study has looked into the
perspectives of patients with psychological illnesses living in rural areas in Jordan when it comes to the
management and awareness of their condition, barriers to adherence, and the role of the pharmacist.

2
This brings us to the aim of this study, which is to investigate perspectives of patients diagnosed with
psychiatric disorders, living in rural areas in Jerash, Jordan, regarding their awareness about their psychiatric
Posted on Authorea 28 Aug 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159862973.35431637 — This a preprint and has not been peer reviewed. Data may be preliminary.

conditions and their treatment, adherence to their treatment, and related barriers, with special focus on the
pharmacist’s role.
Methods
Study Setting
The study objectives were addressed via a descriptive cross-sectional face-to-face survey, conducted in Ja-
rash, Jordan, from August to November 2019. Jerash is located in Northern Jordan, and although it has a
population of about 50,745, it is surrounded by a large number of remote and rural areas that lack specia-
lized hospitals, making Jarash Hospital (located in the city of Jarash Governorate) the center of care and
medication provision for many patients.
Data were collected from patients diagnosed with psychological conditions visiting the out-patient psychiatric
clinic at Jerash Hospital, following the specialists’ informed consent. Ethics approval was obtained from
the Faculty of Pharmacy, Applied Science Private University. Participation in the study did not pose any
risk to patients and was voluntary. Patients who accepted to participate in the study and met all of the
inclusion criteria were informed about the nature of the study and were asked to provide a written consent
before participation. The inclusion criteria were patients above 18 years of age, diagnosed by a specialist
with a psychiatric disorder, and is currently taking a medication for a psychiatric disorder with no change
in treatment and/or dose for the past one month. Exclusion criteria included the presence of a cognitive
problem or a sensory impairment which could prevent communication with the patient, those who rely on
their parents/caregivers to visit the psychiatric clinic in order to obtain their medication/s (hence physically
were not present), and patients not able to write and/or read Arabic.
Study tool
The study tool (the survey) was developed following an extensive review of the literature. The survey
contained close and open-ended questions. The questionnaire was administered in Arabic since Arabic is the
official language of patients in Jordan. Several sources were used to generate a pool of questions considered
to be relevant to the study objectives. The questions were tabled and reviewed by the research team in order
to combine concepts and to remove duplicates if any.
To ensure face validity, the first draft of the questionnaire was evaluated by independent academics who have
previous experience in pharmacy practice and education. The items in the questionnaire that were not clear
or difficult to comprehend were removed. Feedback and comments provided were considered by the research
team and then incorporated where appropriate. Finally, the research team revised the items as necessary to
make them concise and to be completed within 10-15 minutes by the researcher during patient’s interview.
The questionnaire was then piloted by a group of volunteer patients (n=5) to test the clarity of questions
over a 2 weeks period. Refinements and comments were incorporated into the final version of the survey.
The survey incorporated Likert scale questions and consisted of three parts. The first part was designed to
collect data on patients’ demographic characteristics including age, gender, weight, exercising, caffeine intake
and insurance coverage. The second part was designed to assess patients’ awareness of the management of
their condition, adherence, barriers to adherence, faith level and its impact on their adherence. The third
part was designed to evaluate patients’ perspective of the role of healthcare professionals, with a focus on
the pharmacist role.
Survey implementation
Following recruitment, patients were asked by practiced researchers (n=2) to answer the survey items found
in the survey as the items were read out by the researchers. A female pharmacist approached female patients,
and a male pharmacist approached male patients. Both researchers practiced together well to unify the way
they approached and interviewed the patients. Patients were given the time needed to complete the survey

3
(10 to 15 minutes). Patients who completed the survey observed the researcher as she/he inserted it in a
sealed envelope. Every envelope was given a number for participant privacy.
Posted on Authorea 28 Aug 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159862973.35431637 — This a preprint and has not been peer reviewed. Data may be preliminary.

Data were coded and all completed surveys were kept in a locked cabinet that was only accessed by the
researcher. Following data entry, data were kept in a computer with a password protection known only by
the researcher.
Following survey completion, data verification was done by the researcher including age, medical condition/s,
date of treatment commencement, name of medication/s, dosage, therapeutic regimen and reason of use from
the computerized hospital data.
Data analysis
Data were analyzed using the Statistical Package for the Social Science (SPSS) version 22 (SPSS Inc.,
Chicago, IL, USA). The quantitative variables were described using mean and standard deviation (SD),
and the qualitative variables were described using frequency and percentages. Pearson’s χ2 test was used to
determine the relationship between adherence level to treatment and selected variables. Correlation testing
exploring associations between the different variables was identified using Pearson’s correlation and Pearson’s
χ2 test for significance. A probability value of < 0.05 was considered to be statistically significant for all
analysis tests.
Results
Demographics, diagnosis, and treatment :
A convenience sample of 150 patients attending the outpatient psychiatric clinic located in Jerash Hospital
was approached. Eligible patients (n= 120, response rate of 80%) who accepted to complete the survey and
gave consent were recruited into the study. The mean age of patients was 39.4±9.5 and the mean weight
was 78.7± 18.2. More than half of the patients were males (66.7%), most of them (68.3%) reported not to
perform any exercise, and 75% of the patients had health insurance (Table 1). Only 32.6% of the patients
were employed before their diagnosis, and more than half of these patients (56.5%) reported loss of their job
due to their psychological illness.
With regard to the type of diagnosed psychological illness, more than half of the patients (53.3%) reported
being diagnosed with depression, followed by schizophrenia (30%), obsessive compulsive disorder (9.2%) and
Bipolar (7.5%). No family history of a psychological illness was reported by 70.8% of the patients.
Most of the participants (87.5%) agreed that they have a psychological illness, 2.5% were not sure, and
10.0% were not convinced. They reported that their first psychological symptom started at a much earlier
age (27.2±1.2) when compared to their current mean age (39.4±9.5).
Almost all of the patients (98.4%) reported that they started taking a medication to treat their psychia-
tric disorder. It was the specialist who advised the patients to start taking their medication in most cases
(97.5%). The medications used by the patients included antidepressants and antipsychotics (Table 2), com-
prising mostly Citapram® (citalopram, 21%), Kemadrin® (procyclidine hydrochloride, 14%), and Haldol®
(haloperidol Injection, 13.5 %).
Patient perspectives about their psychiatric disorders and their medications :
Following medication use, less than half of the patients (47.5%) reported complete control over their illness.
Others reported partial control (43.3%), while few reported poor control (9.2%).
A deeper insight into patient’s perspectives of the causes that led to their physiological illnesses (Figure
1) included family problems (41.0%), death of a beloved person (20%), work problems (15%) and financial
problems (10%). Patients reported that they visited the specialist merely due to the advice of a family
member (74.2%), others followed the general practitioner’s advice (10.8%), and 8.3% visited the specialist
based on their own decision.

4
Around half of the patients (51.7%) believed that their medications lead to addiction, yet they reported that
this did not prevent them from taking it. Some patients (46.7%) believed that their medications do not cause
Posted on Authorea 28 Aug 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159862973.35431637 — This a preprint and has not been peer reviewed. Data may be preliminary.

addiction. Two patients said that they do not take their medication because they believed it might cause
addiction.
The sources of information about psychiatric illnesses are important for psychiatric patients and are reported
in Figure 2. It was the specialist who gave the patients such information in most cases (92.5%), followed
by the use of the internet (3.3%), or via a pharmacist consultation (1.7%). When patients were specifically
asked about the source of information regarding their medications (Figure 2), the majority reported that it
was the specialist (78.3%), followed by the pharmacist (14.2%) then the internet (5.8%).
When asked if they had questions about their psychiatric illnesses which were not answered, most patients
responded that this never (46.7%) or only slightly (19.2%) happened. When asked if they had questions about
their psychiatric medications that were not answered, most patients responded that this never (58.3%) or
only slightly (15.0%) happened. Reasons for not getting answers about medications included neither visiting
nor calling the specialist in the first place (29.2% of all patients), the specialist did not give enough time
(6.7%) and neither visiting nor calling the pharmacist (5.8%).
Patient awareness and preference of psychotherapy :
Most of the patients (89.2%) did not hear about psychotherapy before, and all of them were never exposed
to it prior to study entry. After psychotherapy was explained to the patients, the majority (65.9%) of them
strongly agreed/agreed that they would have chosen psychotherapy prior to starting treatment if they had
known about it before (9.2% were neutral and 25% strongly disagreed/disagreed).
Adherence to treatment and barriers :
Most of the patients (71.0%) responded that they always/usually adhere to their medications. The most
frequent barrier to adherence reported by the patients was suffering from adverse effects (31.9%). Others
reported different barriers, such as being unconvinced that they needed a medication (23.3%), believing that
their illness symptoms would get resolved without the use of a medication (11.2%), and not being able to
afford their medication when it was not provided by the hospital (11.2%).
A high proportion of patients (59.2%) reported that they regard their psychological illness in terms of
religious faith as counting for their benefit in the Hereafter and these patients reported a significant better
adherence to treatment (Pearson correlation, p=0.046).; others (10%) believed their illness is a sort of divine
punishment, while the rest thought it was neither due to the pre-mentioned reasons (30.8%).
In response to questions related to perceived public psychiatric disorder stigma and self-stigma, 52.5% of
patients always/usually looked at themselves positively and unaffected by the existence of their psychiatric
problem; which correlated significantly (r- 0.394, p<0.001) with better treatment adherence. On the other
hand, 41.7% said that the felt embarrassed that their family, friends, or people in their surrounding know
that they are taking a medication for a psychological problem.
As for adherence to the advice provided by the specialist, the majority (89.2%) reported that they would
not stop taking their medication on their own even if their symptoms faded away. Others (10.8%) reported
that they would stop taking their medication gradually once their symptoms disappeared.
Discussion
This study is the first to evaluate psychiatric patients living in rural areas in Jordan with regards to their
perspectives of their illness, adherence to treatment, barriers to adherence, and the role of the pharma-
cist. Results revealed that less than half of the patients reported complete control of their symptoms with
treatment, and most of them always/usually adhered to their treatment.
Religious and cultural perspectives were unveiled; as the majority of patients (72.5%) believed that the
psychiatric disorders are never/slightly caused by a weakness of faith. Also, 69.2% of them dealt positively

5
with their illness as being counted for their favor in the Hereafter; this positive outlook about their illness
correlated significantly with better adherence to drug therapy (p<0.046).
Posted on Authorea 28 Aug 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159862973.35431637 — This a preprint and has not been peer reviewed. Data may be preliminary.

Barriers to adherence included mainly suffering from medication adverse effects. Only 14% of patients re-
ported that they refer to the pharmacist to get information about their medications.
The study unveiled high rates of perceived public psychiatric disorder stigma and self-stigma in patients
who do seek medical help. This is just one part of the more general picture since mental health stigma and
low mental health literacy were previously found to be the most powerful barriers to seeking help (25). In
this current study, anecdotal comments provided by patients and their families present at the study clinic
indicate that many mental health patients in the rural areas in Jordan do not come to the hospital to
pick up their medications. Such behavior cancels out any chance of being counseled and educated by the
pharmacist or even other healthcare professionals and delivery of evidence-based therapy. This highlights the
importance of socially destigmatizing these disorders in rural areas, in which local pharmacists can play a
crucial role. Mental health education programs have been shown to positively impact mental health literacy
and stigmatizing attitudes and may be an effective tool to use in rural areas (26).
In this study, most of the patients relied on the specialist to get information regarding their mental illnesses
and treatment. Similarly, a previous study in Northern Jordan reported the same finding, as the majority
(68%) of patients referred to their specialists for information about their treatment (27). Although pharma-
cists are the experts in medication use; lack of mental health counselling skills might be the cause behind
this hindered role (28). To be able to provide professional care to those patients, pharmacists should improve
their skills and reflect on their attitude and belief when assisting patients in need (29, 30).
Unlike pharmacists at community pharmacies, who are highly accessibl\soute, pharmacists in public hospitals
of rural areas like Jerash have weaker chances for counseling the patient, since medications get dispensed
through a window to patients or the patients’ relatives who would usually be standing in line before receiving
their medication, presenting physical and time barrier prohibiting optimal pharmacist care.
It has been acknowledged previously that the majority of Muslims depend on their religious believes when it
comes to coping with their mental distresses (19-22). This fact was consolidated through a study conducted in
Jordan previously, which involved patients with mental disorders who reported that religion is an important
factor affecting their treatment (31). In this study, 69% of the patients associated their mental illness with
their faith, considering it a source of good deeds.
In a previous study on psychiatric illnesses, the leading factors for medication nonadherence were: “not
willing to use medication”, “not accepting the disease”, and “being disturbed by side effects” in the bipolar
disorder group, “not accepting the disease” in the schizophrenia/schizoaffective disorder group, and “feeling
well” in the depression group (32). In our study, the main reason for reported nonadherence was suffering
from adverse effects, which signifies the early involvement of the pharmacist in the management plan to
recognize and resolve these adverse effects in collaboration with the psychiatrist.
Psychotherapy based interventions for mentally ill patients have been shown to be effective for this group of
patients (33-36). Most of the patients in this study did not know about psychotherapy and reported that they
would have chosen it before medications if they had known about it in the first place. Including psychotherapy
in the management of these patients, as an adjunct therapy with the pharmacological treatment used, is
important and can improve patient’s adherence to treatment (34). It could be associated with less stigma
barrier and increase the patient courage to seek help.
One recommendation from our research is for the academic institutes in Jordan to introduce the subspecialty
of “psychiatric pharmacy”, in which the pharmacist is provided with specialized knowledge, skills, and
training for working with patients with psychiatric or neurologic disorders (37).
Limitations of the study include the fact that it was conducted in one public hospital, which may not
be representative of the situation in other hospitals and psychiatric clinics in Jordan. This can limit the
generalizability of the study. Another barrier was shown thought the anecdotal comments provided by many

6
people present in the clinic at the time of the study, indicating that a large number of patients do not come
to the clinic themselves to pick up their medications. Hence, the present sample of patients does not cover
Posted on Authorea 28 Aug 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159862973.35431637 — This a preprint and has not been peer reviewed. Data may be preliminary.

those who do not attend the clinic themselves to pick their medications and/or see the specialist.
Conclusion
This study provides insight into the perspectives of psychiatric patients in rural areas with regards to
their illnesses and their medications, adherence, barriers to adherence, and the role of the pharmacist. Less
than half of the patients reported complete control over their illness and most of them reported adherence
to treatment. Positive religious and cultural viewpoints correlated with better adherence, while the main
barriers decreasing adherence included suffering from medication adverse effects and being unconvinced of
the need for medication. Most patients did not know about psychotherapy and most of them declared that
they would have chosen it before medication. Choosing the pharmacist as a source of medication information
was minimal. Relevant strategies should be developed to improve pharmacist participation in identifying
patients in need for help and in dealing with barriers to evidence-based therapy.
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Posted on Authorea 28 Aug 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159862973.35431637 — This a preprint and has not been peer reviewed. Data may be preliminary.

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Table 1. Patients’ demographic characteristics (n=120).

Gender n (%) 80 (66.7) 40 (33.3)


Male
Female
Age group
21-30 26 (21.7)
31-40 38 (31.7)
41-50 41 (34.2)
51-60 61-70 14 (11.7) 1 (0.8)
Exercise None Moderate Regularly 82 (68.3) 16 (13.3) 22 (18.3)
Caffeine intake
None Mild Moderate Sever 7 (5.8) 52 (43.3) 17 (14.2) 44 (36.7
Insurance
Yes No 90 (75.0) 30 (25.0)

Table 2. Medications used by the study participants (n= 120).

Percent % Frequency Drug name


21 33 Citapram (citalopram)
14 22 Kemadrin (procyclidine hydrochloride)
13.5 21 Haldol (haloperidol) Injection
10.3 16 Prexal (olanzapine)
5.1 8 Camcolots (lithium)
4.5 7 Depakin (sodium valproate)
4.5 7 Lexopan (bromazepan)
3.87 6 Rispal (rispridone)
3.22 5 Tegretol (carbamazepine)
2.5 4 Esperal (quetiapine)
2.5 4 Prozac (fluoxetine)
2.5 4 Saroten (amitriptyline)
1.9 3 Eciphram (escitalopram)
1.9 3 Deanxit (flupenthixol)
1.9 3 Gabatrex (gabapentin)
1.9 3 Rivoram (clonzaepam)
1.6 2 Lamictal (lamotrigane)
.6 1 Stilnox (zolpedim)

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Percent % Frequency Drug name
Posted on Authorea 28 Aug 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159862973.35431637 — This a preprint and has not been peer reviewed. Data may be preliminary.

.6 1 Olexa (olanzapine)
.6 1 Cilanem (imipenem)
.6 1 Paroxetine (paroxat)

Figure legends
Figure 1. Patients’ perspectives (n= 120) on the cause that led to their psychological illness.
Figure 2. Source of information about the psychological illnesses and treatments reported by the patients
(n=120).

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