Prevalence and Factors Associated With Pill-Swallowing Difficulties Among Outpatient Pharmacy Attendees at a Malaysian Teaching Hospital: A Cross-Sectional Study.

Abstract

Background: Pill-swallowing difficulty is a common yet under-recognised barrier to effective pharmacotherapy, with potential consequences for adherence, therapeutic efficacy, and patient safety. Malaysian evidence is scarce, particularly in outpatient populations where long-term oral medication use predominates.

Objective: To determine the prevalence, identify associated factors, and examine the consequences of pill-swallowing difficulties among outpatient pharmacy attendees in a Malaysian teaching hospital.

Methods: A cross-sectional online survey was conducted at the outpatient pharmacy of Hospital Al-Sultan Abdullah (HASA), Universiti Teknologi MARA (UiTM), over six weeks in 2025. Adults who received at least one pill (e.g., tablets, capsules or caplets) were invited to complete an electronic questionnaire. Ethical approval was obtained from the UiTM research ethics committee. Binary logistic regression was used to identify associated factors, and descriptive analyses summarised reported problems, coping strategies, medication adherence, psychosocial and behavioural consequences, and consultations with healthcare professionals.

Results: Among 446 respondents, 185 (41.5%) reported difficulty swallowing pills. Compared with participants aged 18-29 years, those aged 30-49 years (aOR = 0.351, 95% CI: 0.177-0.695, p = 0.003) and ≥50 years (aOR = 0.208, 95% CI: 0.094-0.458, p < 0.001) were significantly less likely to report swallowing difficulties. Tertiary-educated individuals had higher odds of reporting difficulties (aOR = 1.878, 95% CI: 1.060-3.328, p = 0.031). A self-reported behavioural pattern of taking pills one by one rather than together was independently associated with difficulty (aOR = 1.636, 95% CI: 1.086-2.462). The most frequent complaints were the sensation of a pill being 'stuck in the throat' (87.0%) and difficulty with caplet shapes (78.9%). Reported consequences included medication non-adherence (36.8%) and psychosocial or behavioural consequences (67.0%). Only 9.7% had sought professional advice.

Conclusion: Pill-swallowing difficulty is prevalent among Malaysian outpatients, with important behavioural and clinical implications. Systematic screening, counselling, and patient-centred formulation strategies are warranted to improve adherence and safety.

What this paper adds: What is already known on this subject Pill-swallowing difficulty, or pill dysphagia, is a common yet under-recognised problem that may compromise medication adherence and treatment outcomes. International studies report that approximately 29%-55% of adults experience difficulty swallowing solid oral dosage forms, sometimes resulting in medication modification, delayed dosing, or non-adherence. Both formulation characteristics and psychological factors influence swallowability. However, most available evidence derives from Western or inpatient populations. Data from outpatient settings in low- and middle-income countries remain limited, despite the central role of long-term oral pharmacotherapy in these contexts. What this paper adds to existing knowledge This study provides outpatient-based Malaysian data on the prevalence and correlates of pill-swallowing difficulty, identifying a prevalence of 41.5%. Younger adults and individuals with tertiary education were more likely to report difficulty, whereas older age was associated with lower odds. A self-reported behavioural pattern of taking pills one by one rather than together was independently associated with reported difficulty. A substantial proportion reported psychosocial or behavioural consequences and medication non-adherence, while few sought professional advice. The findings extend existing literature by characterising behavioural responses and healthcare engagement in a routine outpatient pharmacy setting. What are the potential or actual clinical implications of this work? Pill-swallowing difficulty warrants routine consideration in outpatient pharmacy practice. Incorporating a brief screening question into dispensing encounters may facilitate identification and normalise discussions of swallowing concerns. Pharmacists can provide structured guidance on evidence-based swallowing techniques and advise on appropriate alternative formulations when clinically suitable. Clear referral pathways to speech-language therapists or physicians may benefit individuals with persistent or complex symptoms. Greater attention to swallowability in formulation selection and prescribing decisions may support safer medicine use and improve continuity of pharmacotherapy.