In international studies, the incidence of intestinal stomas is reported to be higher in men than in women.17,18 In Brazil, as in this study, more women had a stoma.19,20 This may be explained by the fact that Brazilian women seek health services more often than men and/or have a higher rate of colorectal cancer.21
Increasing age is a factor in the oncogenic process owing to increased exposure to risk factors over the years. Consequently, the number of ostomy patients increases in this population according to descriptive study by Da Paz et al.22 In addition, a descriptive study by Skeps et al23 (2012) has shown health professionals must understand the implications of age-related changes for persons with a stoma and how they can affect their self-care.
International, demographic, and cross-sectional multicenter studies18,24 conducted in developed countries reveal a population with a high school education. According to a review,25 the illiteracy rate is high (51.6%) in Brazil, especially among the elderly who had no access to school.
The population of Brazilian patients with a stoma includes the most vulnerable economic classes, with family incomes below 3 minimum salaries (<$540 US) and dependent on public health services, which are precarious in the country.26 Pharmacoepidemiological demographic and descriptive studies of persons with a stoma that include a comorbidity profile are scarce.5 A pharmacoepidemiological study27 among persons with a stoma that includes a comorbidity profile showed from 0 to 8 comorbidities, with a high prevalence of cardiovascular, gastrointestinal, endocrine, and neoplastic diseases — conditions commonly found in the elderly. Therefore, in most cases having a stoma does not necessarily imply a limiting condition or poorer quality of health than the general population.
In their qualitative research, Barros et al28 and Silveira et al29 showed chronic degenerative diseases were predominantly found in older populations, making this age group more dependent on health services. Barros et al28 found the elderly with a stoma generally have more difficulties implementing daily care when compared to younger people and often depend on the care provided by other persons or professionals. The health care of this population should focus on disease specificity, the complication risks, and how to live with an ostomy. As such, the current authors believe training of care professionals must be continuous and policies that stimulate their implementation of good practice must be in place.
Polypharmacy and lack of a pharmacist. Chronic degenerative diseases are the factors most associated with polypharmacy.29 Descriptive studies30,31 conducted in different regions of Brazil among patients with chronic degenerative diseases found an average use of 3.6 to 4.67 medications per patient. Polypharmacy also was noted in the study population and contributes to the use of inappropriate and nonessential medication for treatment, which increases the risk of adverse reactions.29 In this study, according to the ATC classification level, persons with a stoma had a medication profile similar to that of the elderly population in general; the most commonly used drugs are agents acting on the renin-angiotensin system, diuretics, calcium channel blockers, psychoanaleptics, and drugs used for diabetes and digestive disorders.31,32
Although the stoma does not typically require use of specific medications, patients will need to use medication for their comorbidities.4 As such, the potential contribution of a pharmacist on a health team should be a considered.32,33 Without proper guidance and monitoring by a professional, intestinal motility, for example, can be affected by medication and interfere with the absorption, effectiveness, and safety of other drugs used concomitantly1,6,34; a pharmacist can provide recommendations on sustained-release medications as well as gastroresistant forms or coated tablets in capsules that can prevent release of the active ingredient at the gastric level in persons with a stoma and advise patients on the use of liquid forms, gelatin capsules, and noncoated tablets.1,4
In this study, the medications used were acquired from retail chain pharmacies, even though 61.81% of the medications referred belong to REMUME. Study data revealed medication is not available through the municipal public health system. One of the factors contributing to this access deficit may be related to the fact that the actions of the pharmacist in drugstores, pharmacies, and basic health units in Brazil are focused on administrative and logistic activities instead of patient care.8,35
Storage. The correct storage of drugs was also a potential problem found among the study population. Proper use of a drug begins with the condition of the product administered; an epidemiological study36 found some people do not observe the drug’s expiration date. Maintaining the quality of the medication, which includes proper storage, is fundamental for maintaining drug effectiveness, and recommended measures always should be taken related to medicine care and stability, along with the dose.36,37
Adherence to treatment. Adherence to treatment was another important factor and current study results corroborated a descriptive study38 conducted among elderly persons with a stoma in which 35.4% were nonadherent to treatment. However, it should be noted that a previous descriptive study14 that used the Morisky Green Levine methodology showed lower scores in identifying low adherence to treatment compared to other methods. As such, reported nonadherence to treatment may be related to the use of a particular questionnaire and whether the interviewer had an expected response bias. Other adherence measurement options such as pill count or therapeutic drug monitoring were not available.
It is worth remembering that treatment adherence is a factor of the guidance received. Potential and urgent problems can arise when the patient does not accept or refuses to follow the treatment regimen. A descriptive study by Oenning et al39 has shown this directly impacts patient safety because the correct medication and its proper administration is a strategic component in the treatment and maintenance of improved quality of life.
From 70% to 98% of patients reported receiving guidance on how to use their medication during their consultation or while the medication was dispensed. Because a method developed in this study to assess the use of medication is a new score created to assess self-reported guidance (see Figure 1), further studies are needed to evaluate the efficacy and reproducibility of the method.
Among patients in the current study who reported receiving (60.4%) and not receiving some guidance (39.6 %), 37% were elderly and 22% had not completed their elementary school education or were illiterate. Therefore, these data must be interpreted with caution because level of education and age could interfere with understanding and processing the instructions received. Information from health professionals promotes the appropriate use of medication, ensuring patient safety. Studies32,39 have shown providing professional guidance is a simple, low-cost strategy for the health system. The level of education is a determining factor in adherence to pharmacological treatment; according to a review study in Ireland,40 data demonstrating a low level of education can contribute to an insufficient degree of adherence with treatment.