The experiences and beliefs of older people in Scottish very sheltered housing about using multi-compartment compliance aids

This was a qualitative study comprising individual face-to-face interviews conducted by a researcher with extensive experience in qualitative interviewing.

The study was conducted within ‘very sheltered housing’ (VSH) complexes in the north east of Scotland. In the UK, ‘sheltered housing’ describes rented housing for older and/or disabled or other vulnerable people, usually in grouped developments. VSH generally has all the features of sheltered housing, but has enhanced care and support through the service of extra wardens, full-time carers, assistance with everyday living, including assistance with medication, and provision of meals.

Residents of three VSH complexes were included if they were aged 65 years or over and had been using an MCA for 6 months or more. Potential participants were identified by the VSH senior carer, who excluded those known to have significant cognitive or welfare issues.

The National Health Service employed primary care lead pharmacist for the area (known to the VSH senior carer) met each screened resident, inviting participation. If the resident was in agreement, signed, informed consent was obtained and a convenient date, time and location for the interview arranged.

Questions in the semi-structured interview schedule focused on: when and why the MCA was first introduced; who was involved in making that decision; how the MCA was used; perceptions of benefit; and any difficulties encountered. The interview schedule was reviewed independently, for credibility, by four individuals with expertise in health services research. This was followed by piloting with two participants fulfilling the eligibility criteria who were then excluded from the main study.

Interviews of approximately 30 min duration took place during September to November 2014. Each interview was audio-recorded, with permission, transcribed verbatim and checked for transcribing accuracy by a member of the research team. Recruitment and data generation continued to the point of saturation when no further themes were emerging from three consecutive interviews.

Members of the research team met to agree consistency of the initial coding framework. Data were analysed using the Framework Approach of: data familiarisation (e.g. reading of transcripts); identifying constructs (e.g. coding relevant statements); indexing and charting (e.g. refining codes and identifying themes and sub-themes); mapping (e.g. refining themes and sub-themes); and interpreting (e.g. interpretation of broader picture of themes and sub-themes). Transcripts were coded independently by two researchers. Whilst SDT was used when interpreting the results, it was not used when planning the study and conducting the interviews.

Twenty residents across three VSH sites (A, B and C) participated; the majority (n = 15) were female, there were no refusals. It was perceived that data saturation, whereby no new themes emerged, occurred after interviewing twenty residents. All were aged 65 years and over, had been using an MCA for a minimum of 6 months, and the VSH senior carer had screened residents to avoid those known to have cognitive impairment or welfare issues. Table 1 gives the nine key themes and corresponding sub-themes identified relating to residents experiences of and beliefs around using MCAs. There were often contradictory experiences and beliefs within the themes.

Although some residents felt that they had been involved in the decision to start an MCA, most reported that they could not recall if they had been involved, or that they had limited or no involvement in the decision,

No, I don’t know how it came about at all, you know? (Case 5 at C).

One resident highlighted the involvement of others in the decision,

My brother was speaking about it and he says ‘you’d be better getting that’. And I says ‘I’ll leave it, one of the lassies’ll [carers will] tell me’ and it was (name), it was (name) that said that I’d be better. (Case 6 at C)

Some described a perceived loss of independence as a consequence of not being involved in the administration of their medicines, with one expressing frustration over the lack of control. Others, however, noted that they did not feel that they had lost any independence by not being in control of their medicines. One was of the view that having the MCA had promoted independence,

I prefer the blister pack, because I mean your dosage is done, it’s taken care of and from time to time, if you want or if you feel capable, you can open it and you look and you see, oh yes, that’s right. (Case 1 at A)

A number of residents recounted their understanding of the purpose of the MCA, that it was required due to reduced capabilities attributable to loss of dexterity, illness and issues with remembering to take medicines. Whilst some residents were aware of why and when they had been provided with an MCA, others were unable to recall when and why it had been started,

Not really. I suppose in case you forgot [medicines]. I don’t know, to take them. (Case 1 at B)

Residents varied in their knowledge and awareness of their medicines, with some having high levels of awareness, knowing what medicines were prescribed for and how much to take. Others, however, reported that with the MCA they had difficulty recognising their medicines,

No, no, I just, well I don’t know if I get anything for it, there’s a lot of tablets I don’t know what they’re for. (Case 2 at C)

There was diversity over the extent to which residents were actively or passively involved in medicines taking. Some discussed that they delayed taking their medicines or chose to take them at certain times, demonstrating ownership and empowerment. For most, their carers prompted or supported medicines taking from the MCA,

They, they do everything, I don’t have a blister pack in my hand at all. (Case 7 at C)

Several residents reported that they were confident that they were competent to manage their medicines. Others reported that they were responsible for taking and managing medicines that were not stored in the MCA. As one resident stated,

…because they don’t realise, I mean I’m 79 year old now, I know what I’m doing, it’s life, I’ve still got my brain up here (Case 6 at B)

The social aspects of having carers support medicines administration from MCAs were highlighted where the benefit of having company was described,

But it’s as much because you get the company of somebody coming in four times a day. It’s good for somebody to come. You’re speaking for a wee while. (Case 6 at B)

MCAs were perceived positively, with residents describing associated benefits, for both carers and themselves, including increasing medicines adherence, enhanced safety and prevention of lost medicines,

Well they make certain that people who might not have full comprehension doesn’t take their tablets at the wrong time and in the wrong sequence (Case 3 at C)

Whilst a number of residents reported no disadvantages to MCAs, the complexities of MCAs were highlighted by several residents, who reported that some medicines were not in their MCA. It was also highlighted by some residents that carers often experienced difficulties in opening and using MCAs,

The lassies [carers], the lassies sometimes have a job themselves. (Case 6 at B)

Personalisation, shared decision-making, independence, reablement and support are key aims of strategies and policies of the Scottish Government [3, 4, 9] and other developed countries around the world [26]. Many of the themes of experiences and beliefs which emerged in this study align to these elements. Shared decision-making and personalisation were apparent in those reporting involvement in the decision to commence an MCA. This was interpreted as an indication that involvement in medicines taking was facilitated through MCA use in those who were competent and capable. Similarly, some residents felt that their independence was promoted through MCA use and many recounted many areas of support derived from MCA use including directly in medicines taking, feelings of empowerment and the carers aiding medicines administration. There were also aspects of reablement, the relearning of skills, in terms of the use of MCAs making medicines taking more manageable particularly on occasions where there were issues with memory, dexterity, eyesight, stress and being overwhelmed. Residents also described their awareness of their medicines and being able to check that the medicines in the MCA were correct, given at the appropriate time and in the prescribed amount. However, as noted earlier, there were examples of polarised experiences and beliefs within the themes with a lack of shared decision-making, personalisation and empowerment, and general feelings that independence was reduced through MCA use. These are important considerations for all health and social care professionals involved in the use of MCAs. These findings are of particular importance for pharmacists and pharmacy staff given their acknowledged roles in the provision and review of MCAs in older people [27]. It may be beneficial for pharmacists and pharmacy staff to explore patient issues around MCA us in an effort to promote shared decision-making.

The issue of non-adherence in those with chronic conditions is widely acknowledged [15]. Given the predictions of the increasingly older population, combined with prevalence of multimorbidity and numbers of prescribed medicines, there is potential for these non-adherence statistics to increase. MCAs represent one potential solution for those whose non-adherence is non-intentional and indeed promoting adherence was noted as a benefit in this study and others [24, 25]. While systematic reviews have failed to demonstrate objectively that MCAs improve adherence [21, 22], there are particular issues around obtaining valid and reliable measures of adherence in those receiving MCAs. The perspectives of the individual and their attendant carers and health professionals should therefore not be underestimated. There is a need to ensure, however, that MCAs are targeted to the correct individuals, and there is strong evidence of the need for review of all medicines [28‐31].

It is clear from the findings of this study that the experiences and beliefs around MCA use in older people are very individual and hence diverse. The elements of personalisation, shared decision-making, independence, reablement and support may all relate to, and be interpreted, by SDT. The themes ‘knowledge and awareness of why MCA commenced’, ‘support in medicines taking’ and ‘independence’ may all be encapsulated within the SDT need for autonomy. Specifically, in relation to MCAs, residents demonstrated varying levels of autonomy in relation to management of their medicines with some reporting a high degree of responsibility and others, limited involvement in the process. The themes ‘knowledge and awareness of medicines’, ‘competent and capable to manage medicines’ may pertain to the competence need of SDT. Residents often demonstrated a desire to manage their own medicines since they felt capable of doing so, however, conversely, others were relatively happy to absolve responsibility of managing their medicines since they believed they were less capable. The ‘social aspects of carers supporting MCA use’ may relate to the relatedness need outlined in SDT. Residents discussed the role of the carer in managing medicines and how this was considered to be a more social aspect of having an MCA.

Perhaps, prior to initiation of an MCA, it may prove beneficial for health and social care professionals to consider the individual needs of residents in relation to using MCAs within the context of SDT. Performing tailored theoretical analyses of residents’ psychological needs may aid personalised goal setting and plans for monitoring MCA use thereafter. The tenet of personalisation may be particularly important moving forward. Custer et al. in a study of need fulfilment in nursing home residents using SDT as a foundation, highlighted the individuality and variability in how residents perceived the importance of autonomy and competence. Although being provided with the opportunity to make decisions and complete tasks independently were critical factors in ensuring fulfilment of needs for some, they were not priorities for others [32].

There are several strengths to this study which are based around the measures to promote credibility (e.g. adopting research methods well established in qualitative investigation, expert review of the interview schedule, iterative questioning, encouraging residents to be frank in their responses), dependability (e.g. an experienced qualitative interviewer) and transferability (e.g. detailed description of setting and participants). It is also highly likely that the sample size was sufficient for saturation of themes and issues. There is also a lack of qualitative research in this field hence the findings contribute to this limited evidence base. In particular, the emphasis on the residents’ perspectives of experiences and beliefs complement our overall case study based approach which sought to elucidate behavioural determinants of MCA use [25]. The study adds to existing literature on MCAs in that it has contributed to enhanced understanding of MCA use in older adults. There are, however, study limitations most notably the issue of transferability of the findings to older people resident in other settings and countries with different health and social care systems. Whilst the results were viewed through SDT, the theory did not inform the design of the study and hence, greater depth may have been attained around the three tenets of theory had it been. Furthermore, the findings may be impacted by recall bias, particularly around issues of reasons for commencing MCAs which may have occurred in the distant past.

Further research should now focus on exploring SDT within the context of MCA use in older people. Personalisation should be a key consideration since it would assist in ensuring that an individual’s priorities, in terms of psychological needs, correspond with the support that is provided in relation to management of medicines. Hence, wellbeing may be optimised within the population by maintaining congruence with regard to both preferences for managing medicines and experience.