The Impacts of using community health volunteers to coach medication safety behaviors among rural elders with chronic illnesses

Abstract

It is a challenge for rural health professionals to promote medication safety among older adults taking multiple medications. A volunteer coaching program to promote medication safety among rural elders with chronic illnesses was designed and evaluated. A community-based interventional study randomly assigned 62 rural elders with at least two chronic illnesses to routine care plus volunteer coaching or routine care alone. The volunteer coaching group received a medication safety program, including a coach and reminders by well-trained volunteers, as well as three home visits and five telephone calls over a two-month period. All the subjects received routine medication safety instructions for their chronic illnesses. The program was evaluated using pre- and post-tests of knowledge, attitude and behaviors with regard to medication safety. Results show the volunteer coaching group improved their knowledge of medication safety, but there was no change in attitude after the two-month study period. Moreover, the group demonstrated three improved medication safety behaviors compared to the routine care group. The volunteer coaching program and instructions with pictorial aids can provide a reference for community health professionals who wish to improve the medication safety of chronically ill elders.

Introduction

Many older adults use multiple medications for various illnesses and conditions.1, 2 This population is a significant consumer of prescription medications with a greater risk of medication-related adverse health events.3, 4, 5, 6, 7, 8, 9 Adherence to medication safety is defined as the extent to which a patient's actual drug regimen, in terms of dosage, time and mode of administration of the medications, corresponds to the providers' prescriptions.¹⁰ Safety issues related to the use of multiple medications are a significant concern to both the older adults and their health care providers.

Inappropriate medication use is a major source of drug-related problems among elders.¹¹ The risk factors for inappropriate use of medication for community-dwelling elders have been identified as poor economic situation, living alone, multiple medication use, erroneous medication consumption, and lack of instruction from health professionals.4, 12, 13 In addition, the main barriers to medication adherence among elders include forgetting to take medications, poor organizational skills, belief that a drug is ineffective or unnecessary, and an inability or unwillingness to pay.¹⁴ Epidemiological studies have found that rural-dwelling elders, as compared to urban-dwelling ones, have poorer physical health and more chronic diseases, with lower incomes and a lack of medical resources, conditions that can exacerbate their health problems.15, 16 Therefore, the challenge faced by community health professionals is to develop an appropriate approach and support system which takes the related factors and obstacles into account to promote medication safety behaviors for elders residing in rural areas.

Many strategies have been suggested to improve medication adherence, and thus safety, for older adults. Research in the field of psychology and education indicates that picture-based information can serve as a more effective learning tool for older adults than text-based materials.¹⁷ Kountz¹⁸ demonstrated that effective strategies to overcome poor health literacy include conveying a few key points at each of the subject's visits, the use of jargon-free communication and pictures to clarify concepts, and confirmation of the subject's knowledge via the “show-me” or “teach-back” method. Other studies have reported a variety of effective strategies to raise medication safety knowledge among elders, including simplifying medication regimens, using medication tools, such as simple self-filled medication-sets,¹⁹ medication labeling with color-specific symbols,²⁰ and graphic knowledge representation tools.²¹

While strategies to increase medication safety among older adults that include an individualized approach have been shown to be effective, less attention has been paid to community-centered approaches. It remains especially challenging for health care providers to design, implement, and maintain an appropriate medication regimen for a community-dwelling elderly population. One method suggested by Bergman-Evans,²² described the AIDES (Assessment, Individualization, Documentation, Education and Supervision) program to improve the medication adherence of community-dwelling older adults. Several other researchers have designed a number of strategies and programs to improve medication adherence and decrease related errors among community-dwelling older adults with chronic diseases; the results indicated that self-reported adherence improved significantly.21, 23, 24, 25, 26 The effective strategies used in these programs included appropriate advice and information provided by pharmacists or nurses, the involvement of family members, telephone reminders, the use of drug boxes, and interactive, pictorial educational material. However, such programs require significant allocation of professional resources and a well-developed system for successful implementation. Remote rural areas, with fewer resources, must identify suitable alternatives.

One alternative is the use of health advocates or local volunteers.²⁷ The advantage of using volunteers or outreach workers to implement health programs in remote areas lies in the reality that local people with similar ethnic backgrounds find it easier to gain trust in the community. Thus, the likelihood of community residents accepting help and information is increased.27, 28 In South Carolina, Forti²⁹ designed a program using trained outreach workers as geriatric coordinators for older African-Americans. The coordinators linked clients to needed health and social services and provided rural care management outreach interventions. Improvement in quality of life outcomes demonstrated that the use of outreach workers was feasible and effective.

Based on a volunteer model, a pilot program was designed to improve the medication safety of rural elders. Community volunteer coaches were trained and functioned as monitors, reminders and supporters to promote medication regimen compliance. Program evaluation included medication safety knowledge, attitude and behaviors of the chronically ill rural elders toward medication safety.