Papers
Patient acceptance of a tablet
Arne Christensen
Division of Social Pharmacy
Department for Pharmacology
and Pharmacotherapy
The Danish University of
Pharmaceutical Sciences
Universitetsparken 2
2100 København Ø, Denmark
Tel: + 45 3530 6350
Fax: + 45 3530 6050
e-mail: ach@dfuni.dk
152 Journal of Medical Marketing
reminder device
Received (in revised form): 10th November, 2006
Arne Christensen
has a Masters in Pharmaceutical Sciences from the Christian Albrechts University in Kiel, Germany. The work for his master’s
degree was carried out in cooperation with AstraZeneca R&D Mölndal, Sweden. After his graduation, he worked in a public
pharmacy in Germany, directly facing patient’s compliance problems in everyday work. He is working on his PhD project entitled
“The Impact of Intelligent Medical Packaging and Devices on Treatment Adherence” at the Danish University of Pharmaceutical
Sciences in Copenhagen, Denmark in cooperation with Bang & Olufsen Medicom a/s. The methods applied in his project include
survey research and clinical trials.
Lona Louring Christrup
is Associate Professor at the Department of Pharmacology and Pharmacotherapy at The Danish University of Pharmaceutical
Sciences in Copenhagen. Her research is focused on the dose–response relationship of analgesic substances, including factors
as dosage form, administration route, pharmacokinetics, pharmacodynamics, patient acceptance and compliance.
Paul Erik Fabricius
is Concept Development Manager at Bang & Olufsen Medicom a/s. He is responsible for the creative and strategic processes
in business and product development and has more than 15 years of experience in the medical device industry. He has a basic
education as BSc EE in Mechatronics. In recent years, Bang & Olufsen Medicom has been associated with four design awards for
their drug delivery device and diagnostic solutions. He has been responsible for the concept development of these products.
Ebba Holme Hansen
is professor of Social Pharmacy at the Danish University of Pharmaceutical Sciences. She is also the Director of the
multidisciplinary and inter-institutional Research Center for Quality in Medicine Use. She has been the backbone of Social
Pharmacy in Denmark since inception. Her major research interests are: user perspectives on medicines, popular perceptions
and attitudes versus medicines, children’s medicine use, development of knowledge on medicines’ safety, medicines in developing
countries. She has published extensively on these and other topics and is frequently invited to speak to Danish and international
audiences.
Keywords drug packaging, internet survey, patient adherence/compliance, patient
satisfaction, reminder systems, The Helping Hand™
Abstract The objective of the study was to examine patients’ acceptance of and
attitudes towards a new tablet reminder and protective device. The study was designed
as an internet survey. Respondents entering the survey site received an introduction, an
animated presentation of a tablet reminder device and a questionnaire consisting of
close-ended questions, followed by open-ended questions. The survey was completed
by 403 respondents. The overall assessment of the functions of the device, its
usefulness and design were very positive, with few negative comments. Of the
respondents, 87 per cent found the tablet card protection to be excellent or acceptable
and 85 per cent of all respondents found the reminder function excellent or acceptable.
The feedback function received 80 per cent positive answers. Usefulness and design
were assessed comparably. Respondents older than 60 years and respondents receiving
more than six different medications a day assessed the device less positively. Only the
oldest patients assessed the protective function of the device significantly less positive.
Otherwise, no significant differences could be found. The majority of respondents, users
Vol. 7, 2 152–161 © 2007 Palgrave Macmillan Ltd 1745-7904 $30.00
www.palgrave-journals.com/jmm
 Patient acceptance of a tablet reminder device

as well as non-users, irrespective of their demographic and socio-economic background,

reported a high acceptance of the device functions, its usefulness and design. The
concept of the device is less appropriate for patients receiving more than six different
medications. Patients acceptance of medical devices is crucial for devices used in
everyday life. Hence, an attractive design and an easy to understand functionality are
crucial for new medical devices.
Journal of Medical Marketing (2007) 7, 152–161. doi:10.1057/palgrave.jmm.5050076

INTRODUCTION devices like pill boxes, pill bottles and

Poor adherence to therapeutic regimens
can have a serious impact on a patient’s
health and may even lead to death.1–3 In
many treatment areas, including pain,
epilepsy and immune suppression after
organ transplantation, nonadherence might
have immediate negative health impacts
like reoccurrence of pain, seizures or
organ rejection.4–6 In other therapeutic
areas such as treatment of hypertension
low adherence rates may not have
immediate negative consequences for the
patient, but in the longer term may
increase the risk of stroke, myocardial
infarction, dementia and renal
dysfunction.7 In addition, poor treatment
adherence may result in reduced quality of
life for the patient, lost productivity and
increased healthcare costs.3
Strategies to help patients follow
medication dosage schemes include
simplification of treatment regimens, more
convenient care, more thorough patient
instructions and counselling, close follow-
up, supervised self-monitoring, rewards for
success, family therapy, psychological
therapy, crisis intervention, manual
telephone follow-up and telephone
reminders. In spite of the amount of effort
and resources they consume, these
complex strategies for improving
adherence with long-term medication
prescriptions are, however, not effective in
the majority of patients.8
Many medical technologies such as
tablet dispensers and reminders have been
developed. These include all-mechanical
additional features of the primary
packaging (calendars printed on the blister
cards of oral contraceptives, wallet packs).9
Most of these aids may contribute to
improved adherence; however, so far little
has been reported about their effects in
high-quality medical literature and even
less about patient acceptance of these
aids.9 In our literature search, we have
identified only three smaller studies from
around 1990 on the assessment of patients
acceptance and satisfaction with
mechanical compliance devices, containing
one week supplies of medication.10–12
Despite the fact that many patients initially
were not aware of the existence of such
devices, 60–90 per cent of patients in all
three studies assessed most of the tested
compliance aids positively after having
used them and would like to continue to
use these devices once having been
introduced to them.
A prerequisite for improving adherence
with medical devices is the user’s willingness
to accept them as part of their everyday
life.12 The objective of this study was to
assess patients’ acceptance of a new tablet
dispenser, with respect to the functions,
design and usefulness of the device.
METHODS
The device
‘The Helping Hand™’ (THH) is a new
intelligent reminder and protective device
(Figure 1).13 Medication packaged in a
blister card is slid into the device that

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 Christensen, Christrup, Fabricius and Hansen

introduction, an animated presentation of

Figure 1: The Helping Hand™
features an audio-visual reminder. A
feedback on actual adherence can be
relayed to the patient with a visual signal
(red for poor, yellow for average and
green for good adherence).
Study design
The present study was designed as an
internet survey directed towards patients.
Most respondents entered the
questionnaire via an invitational link on
www.cipralex.com or www.cipramil.com
(antidepressant drugs), hosted by a
pharmaceutical company, thus making it
possible for any interested individual to
participate in the survey. Respondents
activating the link were redirected to the
internet site www.the-helping-hand.com.
Respondents entering this site received an
the reminder device, as well as a basic set
of closed questions. The questionnaire was
started by filter questions on, for example,
the respondent’s former knowledge of the
device, followed by more specific questions.
One of the filter questions redirected
health professionals to another survey.
Some of the questions intended for
patients and their close-ended responses are
presented in Table 1. Multiple submissions
were eliminated by excluding any repeated
submission from the same email addresses.
Data collection was conducted from
November 2004 to March 2005.
Statistical analysis
Answers were included in the analysis only
if respondents had completed the full
questionnaire. Data were collected in a
Microsoft Access database and analysed
using SPSS 14 statistical software.
Data from binary questions were
dichotomised and scores of 1 and 0 were
assigned. The scores of the categories
‘Poor’ and ‘Bad’ of the questions 1, 5, 6
and 7 (Table 1) were merged before
statistical analysis, due to very low
responses in the category ‘Bad’. Statistical
significance was tested by Pearsons chi-
square test and Fisher’s exact test. The
exact test was applied for the comparison
of assessments of respondents aged 60
years or more with the gathered remainder
of the population only, due to a small
number of respondents in this age group.

Table 1: List of questions and their close ended responses

1. How do you rate your own health? (Excellent/Good/Fair/Poor/Bad)

2. Do you suffer from diseases in any of the following categories (please check all that applies)?
(Cardio-vascular/Hormonal (including diabetes)/Respiratory (including asthma)/Nervous system/
Musculo-skeletal/Other)
3. How many tablets do you have to take each day? (prompt)
4. Do you have to take all tablets at one time of day, for instance in the morning? (Yes/No)
5. What is your impression of the tablet card protection? (Excellent/Acceptable/Neutral/Poor/Bad)
6. What is your impression of the reminder function? (Excellent/Acceptable/Neutral/Poor/Bad)
7. What is your impression of the feedback function? (Excellent/Acceptable/Neutral/Poor/Bad)
8. How would you characterize the tablet dispenser (please check all that applies)? (Discreet/Tasty/Elegant/
Relevant/Unnecessary/Inconvenient/Other/If other please specify)
9. How would you estimate the value of the tablet dispenser to you?

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 Patient acceptance of a tablet reminder device

Data from continuous variables like age Table 2: Background characteristics of respondents
or number of tablets per day were in percent (N=403)

grouped in categories for parts of the Characteristic (% of respondents)

statistical analyses. Statistical significance Age
was tested by Pearsons chi-square test. A < 25 24.1
26–35 31.8
level of significance of 0.05 was applied 36–45 22.3
for both tests. For power calculations, a 46–60 18.9
61+ 3.0
two-sided level of significance of 0.05 was
applied and 80 per cent power was Gender
considered sufficient. Male 39.2
Female 60.8
Data from open questions were grouped
according to characteristics like specific Cohabitation
Yes 88.5
functions or the devices design to get a No 11.5
deeper understanding of patient’s
Education
preferences, explanations and possible Elementary School 8.9
problems with the device. College 51.4
Academic 39.7

Number of tablets taken per day

RESULTS Max 1
Max 3
52.4
29.5
The survey was completed by 403 patients Max 5 8.4
of whom 25 had experience with the use 6 or more 9.7
of THH. The mean age of respondents Self-rated health
was 36 years, with only a minority aged Excellent 9.7
Good 41.4
60 years or more (see Table 2). Fair 36.0
Approximately, 60 per cent of the Poor 12.9
respondents were female, less than 10 per Disease (adds up to more than 100%,
cent were single; more than 90 per cent as respondents may suffer from more than
had a college or university degree. Less one disease)
Cardio vascular 7.2
than 20 per cent were taking more than Hormonal (including 8.9
three different tablets daily. Approximately, diabetes)
Respiratory 9.2
half of the respondents rated their own Nervous system 57.8
health as excellent or good and almost 60 Musculo-skeletal 7.9
Other 12.7
per cent were suffering from a disorder of
the nervous system.
As shown in Figure 2, Tables 3 and 4,
the reminder function was regarded as significant differences could be detected
excellent or acceptable by over 85 per regarding any of the background
cent of all respondents, approximately 10 characteristics. More than 80 per cent of
per cent were neutral and less than 5 per the respondent assessed the protective
cent judged the function as poor or bad. function of the device as excellent or
This assessment is similar and without acceptable with no significant differences
significant differences between users and between the various groups.
nonusers of the device, across different age In the small group of current users, a
groups, gender and the various tendency can be seen to a slightly more
background variables. positive assessment of the device, but due
Nearly 80 per cent of the respondents to the small number of respondents in this
reported the feedback function to be group the power (1 −
) is too low to
excellent or acceptable (Table 3). No detect a significant difference (power

© 2007 Palgrave Macmillan Ltd 1745-7904 $30.00 Vol. 7, 2 152–161 Journal of Medical Marketing 155
 Christensen, Christrup, Fabricius and Hansen

Figure 2: Opinion of current users (N = 25) and other respondents (N = 378) on the three main features of the
device: reminder, feedback, protection. p-values from Pearson chi-square test

reminder, 0.15; power feedback, 0.03; however, no statistical significant difference

power protection, 0.35). In the oldest
group of respondents, a general tendency
to a less positive assessment of all three
functions can be seen compared to all the
other age groups, as shown in Table 3;
could be demonstrated, probably due to the
small number of subjects in this group.
Comparison of this oldest age group with
the younger respondents shows a significant
difference for the protection function only

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 Patient acceptance of a tablet reminder device

Table 3: Opinion of respondents on reminder, feedback and protection function by age (in per cent)
Age % of respondents
< 25 26–35 36–45 46–60 61+ Total
(N=97) (N=128) (N=90) (N=76) (N=12) (N=403)

Reminder (p=0.138)
Excellent 56.7 59.4 53.3 57.9 33.3 56.3
Acceptable 30.9 26.6 27.8 31.6 33.3 29.0
Neutral 6.2 10.2 17.8 7.9 33.3 11.2
Poor/Bad 6.2 3.9 1.1 2.6 0.0 3.5

Feedback (p=0.306)
Excellent 47.4 55.5 37.8 48.7 25.0 47.4
Acceptable 32.0 25.8 35.6 31.6 50.0 31.3
Neutral 17.5 15.6 23.3 15.8 25.0 18.1
Poor/Bad 3.1 3.1 3.3 3.9 0.0 3.2

Protection (p=0.101)
Excellent 48.5 56.3 38.9 55.3 8.3 48.9
Acceptable 37.1 30.5 43.3 26.3 66.7 35.2
Neutral 12.4 11.7 15.6 18.4 25.0 14.4
Poor/Bad 2.0 1.6 2.2 0.0 0.0 1.5

p-values from Pearson chi-square test.

Table 4: Respondents’ acceptance regarding the device’s reminder, feedback and protection function and
regarding design and usability
Background variable p Reminder p Feedback p Protection p Design p Usefulness

Age categories 0.111 0.545 0.062 0.225 0.048*

Gender 0.327 0.690 0.110 0.048* 0.665
Disease area 0.476 0.354 0.913 0.007* 0.682
Number of tablets taken per 0.994 0.846 0.603 0.036* 0.034*
day
All tablets taken at one time 0.319 0.257 0.072 0.018* 0.089
of the day
Self-rated health 0.502 0.348 0.614 0.565 0.654
Cohabitation 0.452 0.848 0.918 0.634 0.427
Education 0.147 0.849 0.687 0.258 0.367
Line of work 0.857 0.757 0.297 0.335 0.492

*p-values from Pearson chi-square test for associations with background characteristics.

(Fisher’s exact test: p reminder, 0.095; p
feedback, 0.318; p protection, 0.017). For
the reminder and feedback function, the
power was too low to detect a significant,
difference (power reminder, 0.65; power
feedback, 0.31; power protection, 0.95).
As shown in Table 5, more than 50 per
cent of the respondents associated the
three terms discreet, tasty and elegant
with the design of the device.
Significant differences in the assessment
of the device’s design were found between
certain background variables of the study
population (Tables 4 and 5). These
included gender, disease area, number of
tablets taken per day and if all tablets have
to be taken at the same time of the day.
Males regarded the device as more elegant
than females, and significantly fewer
respondents in the group taking more
than six tablets each day assessed the
device as discreet compared to respondents
taking less medicines (data not shown).
Three in four respondents associated
the term relevant with the device,
approximately 20 per cent judged it to be
unnecessary and a small minority reported
it to be inconvenient. Overall, the
usefulness of the device was assessed quite
similarly across respondent characteristics;

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 Christensen, Christrup, Fabricius and Hansen
Table 5: Respondents opinion about design and usefulness of the device by gender.
Design (p=0.048*)
Discreet
Tasty
Elegant
Usefulness (p=0.642)
Relevant
Unnecessary
Inconvenient
p-values from Pearson chi-square test.
however, the oldest respondents and those
taking more than six different medicines
per day regarded the usefulness to be
significantly less positive than the remaining
population (data not shown). The group of
the oldest patients regarded the device as
less convenient and, as mentioned above, in
this group there is also a tendency to assess
the functions less positively. Patients in the
older age group were taking 4.8±2.1
(m±SD) tablets per day compared to
2.6±2.5 in the remainder of the population,
but no significant association was detected
probably due to the small number of
respondents in this age group.
Almost 75 per cent of the respondents
would like a reminder on the time of
prescription renewal, almost 66 per cent of
respondents on intake time of their
medication and 56 per cent on when to
purchase a new pack of tablets.
The respondents had the opportunity to
comment on the concept’s value for them
in an open-ended question. The question
was answered by 344 (85 per cent) of
the respondents. Some respondents
commented on the device in general,
some focused on the design or certain
functions like the reminder.
Most comments were positive and
supported the concept like: ‘the device
would help me to work towards full
health’, ‘a visible elegant reminder to take
medication and not feel embarrassed’,
158 Journal of Medical Marketing Vol. 7, 2 152–161
Gender
% of respondents
(several answers allowed)
Male (N=158) Female (N=245) Total (N=403)
54.0 59.9 57.6
50.0 48.8 49.2
55.0 38.3 44.7
72.6 73.0 72.8
23.6 17.6 1.4
5.7 4.4 5.2
‘Extremely valuable. Because of my age I
often forget whether I took my pill’.
Some of the comments were more neutral
like: ‘Looks nice and the reminder feature is
very cool. But I don’t really need it.’
Very few comments were mainly
negative: ‘None; I always remember my
medication’, ‘none really, as I print a tablet
reminder list from my own office excel’,
‘Useless. I take many pills in a day, this
device limits you to one kind of tablet
and the tablets have to come in a blister
strip that fits into it and most don’t and it
is stupid to carry it with you and keep
checking for a flashing light. Stupid’
DISCUSSION
The main finding of this study is that a
large majority of respondents assessed the
three functions as well as the design and
usefulness of the device very positively.
Most respondents were willing to accept
the device. The less positive assessments
from the oldest patients and patients
receiving more than six different types of
medicine a day are generally identical,
since most of the elderly patients use a
relatively high number of medications, but
due to the low number of respondents no
significant correlation could be detected. It
is understandable that patients receiving
many drugs would face practical problems
using several devices at the same time.
© 2007 Palgrave Macmillan Ltd 1745-7904 $30.00
 Patient acceptance of a tablet reminder device
The device evaluated in the present study
does not meet their requirements, which
results in a less positive assessment. The
elderly patients’ less positive assessment
may derive from a general reservation
against new inventions, especially
electronics. This reluctance to use
electronics might decrease in the future as
the coming generations will be more
familiar with different electronic devices as
part of daily life. The principal finding,
that acceptance of and attitudes towards
the device are not greatly associated with
respondents background characteristics,
matches with the lack of influence of the
background on adherence rates themselves,
as described in the literature.3,8 No single
demographic or socio-economic factor
could be identified as a reliable predictor
of compliance rates.14
The positive feedback from the open
question about the value of the device for
patients fits very well with the overall
assessment of the device. Only a minority
assessed the functions negatively and
commented the value negatively. Negative
comments were primarily provided by
patients who did not need additional help
to adhere to their prescribed medication
regimen. They already had found their
own methods to stick to the dosage
scheme. This finding is supported by
results from a previous study, showing that
those patients who had overcome the
challenge of producing their own system
and had taken responsibility of maintaining
high adherence were unlikely to request a
commercial compliance aid.12
The finding, that the concept is
accepted by a majority of patients but not
by all, emphasises the necessity to simply
ask patients about adherence to get their
opinion about their medical treatment15,16
and to assess the individual patients need
for additional help. Such an approach is in
line with the concept of concordance.17,18
In this respect, the traffic light feedback
function of the tablet dispenser assessed in
© 2007 Palgrave Macmillan Ltd 1745-7904 $30.00 Vol. 7, 2 152–161
this study might be a useful facilitator
for the communication between health
professionals and patients.
A few smaller studies have been
published assessing patients opinion on all
mechanical compliance devices containing
one week supply of medicines.10–12 One
of the problems identified in these studies
was patient’s lack of awareness of the
existence of such devices, but in all of the
studies a majority of patients assessed most
of the compliance aids positively after
having used them and many patients
would like to continue using them once
they had been provided with information
about them. The positive attitude towards
compliance aids is in accordance with the
findings of this study.
In one of the aforementioned studies,12
patients assessed the device design as
‘good, but could be better’. This indicates
the importance of a superior design for
the acceptance of a device. The positive
assessment of the devices design in this
study might be a contributor to the
overall positive assessment.
In a previous study,11 concerns were
expressed about the necessity to transfer
the medication from the primary package
into the devices. The device tested in the
present study avoids this problem.
Surveys in general face several validity
problems. One of these problems may
be a lack of knowledge about the part
of the population not participating
(nonrespondents). A general aversion
against the pharmaceutical industry may
have kept some potential respondents from
answering the questionnaire. Another
general problem of surveys is incomplete
responses. In this study, only answers of
respondents completing the whole
questionnaire were included in the
analysis.
Internet questionnaires can give valuable
information from a broad population in a
cost-effective and convenient way under
the condition of awareness of some
Journal of Medical Marketing 159
 Christensen, Christrup, Fabricius and Hansen
limitations. There are several specific
validity issues regarding the present study.
Multiple submissions and the under-
representation of the older segment of
the general population on the internet
are general problems for online
questionnaires,19,20 reflected by the
relatively low share of respondents over 60
years in this study. Multiple submissions
were eliminated by excluding any repeated
submission from the same e-mail addresses.
The study was conducted on the
internet via an invitational link and thus
the identity of respondents cannot be
validated and the population is not well
defined so the findings cannot be directly
generalised. But taking background
variables (age, sex, self reported health,
educational level, consumption of
medication) into account and comparing
the study population in this study with
the population of The Danish Health and
Morbidity Survey 200021 of 16,690
respondents, the main characteristics are
comparable. For example, the average age
of respondents in the Danish survey is 41
years. The average age of respondents in
this study is younger (36 years),
representing the age distribution of the
part of the population using the
internet.19
The education level of respondents in
both studies is quite comparable. In the
Health and Morbidity survey, about 20 per
cent of respondents had an education up
to seven years, 50 per cent up to 12 years
and around 30 per cent having a higher
education. In this study, the distribution is
almost the same with a slight tendency to
higher educations (see Table 1). This might
be explained by a higher representation of
the better-educated share of the
population on the internet. Respondents
in this survey consume more medications
than respondents to the Health and
Morbidity Survey, since a high share of
respondents is undergoing antidepressive
drug therapy.
160 Journal of Medical Marketing Vol. 7, 2 152–161
Taking these similarities and explainable
differences into account, a broad
representative population can be assumed
to be respondents for the study
population, biased by the unusually high
share of respondents with disorders of the
nervous system (see Table 2) resulting from
the location of the invitational link on
www.cipralex.com and www.cipramil.com.
Anyway, it can be assumed that
respondents entering the questionnaire via
this site do not answer the questionnaire
‘just for fun’, but have a serious interest in
the topic. This high share does not affect
the study results as there is no appreciable
significant difference between groups of
respondents with different diseases.
CONCLUSION
The tablet dispenser, its main functions,
design and usefulness are appreciated by
the large majority of the study population.
This finding does not differ greatly with
respondent background except for the
oldest respondents and those taking more
than six different medications. Users of the
device assess it as positive as nonusers.
Eighty per cent of respondents are willing
to accept the device.
The reminder and the feedback
function could create awareness about
adherence in patients and thus facilitate
communication about this important topic
between them and health professionals.
The positive attitude towards the device
and improved communication could help
to create a higher satisfaction with medical
treatment and lead to improved clinical
results.
Although the concept of the described
tablet dispenser is highly appreciated
among patients, it is worthwhile to
examine the actual effect of the device on
adherence rates and clinical results in a
clinical setting. Future research should be
directed this way. The device assessed in
this study is not suitable for patients
© 2007 Palgrave Macmillan Ltd 1745-7904 $30.00
 Patient acceptance of a tablet reminder device
receiving many different medications. For
those patients, the development of other
solutions is desirable and ongoing.
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