Year: 2012
Type: dissertation
Study design: Observational Study
Abstract: Throughout the world the population is ageing and the burden of chronic diseases and co- morbidity is growing. While the appropriate use of medicines help to decrease morbidity and mortality from chronic diseases, research consistently demonstrates that preventable medication-related problems cause unplanned hospitalisation and morbidity. The elderly and those consuming multiple medicines are at greatest risk. Pharmacist-provided medication management services aim to prevent and resolve medication-related problems for those consumers who have been identified as being at increased risk. This thesis deals with consumers' participation in pharmacist-provided medication management services with a particular focus on Australia's Home Medicines Review (HMR). HMR has been shown to improve health outcomes across a variety of research settings. The rationale for the thesis was that some consumers who have been identified as being at risk have declined the offer to use HMR. Many potential consumers of HMR are cared for by informal caregivers such as spouses or other family members (caregivers). Caregivers therefore necessarily have a key role in enhancing consumer participation in medication management services. Therefore, the aim of this thesis was to investigate consumers' and caregivers' awareness, expectations and willingness to use HMR. In order to address the aim, the thesis used cross sectional studies with mixed-methods. Studies included qualitative methods using focus group discussions and quantitative methods using surveys. Given the preliminary nature of the research, survey data was obtained from three different samples in order to validate the measurement scales and to test and re-test hypotheses. Such an approach strengthens the key findings of the thesis. Chapter One provides the background to the study. The literature review identified that consumers' most salient expectations of pharmacist-provided medication management services are those centred on the interpersonal interaction with the pharmacist during the patient-pharmacist interview. While it is acknowledged that these services improve medication safety through for example; enhanced inter-professional communication, goal setting, and optimised therapies, consumers tend to focus on the benefit of receiving personalised medicines information. Given the lack of previous research using behavioural theory to study the factors which influence willingness to use medication management services, a new framework was developed. The research was therefore guided by a conceptual model which was grounded in theories of medication information seeking behaviour. Chapter Two reports a cross-sectional survey which was distributed to patients by 264 pharmacists throughout Australia. A total of 1893 questionnaires for HMR recipients were sent to pharmacists of which 595 (31%) were returned by patients. A total of 1829 questionnaires for consumers who were eligible to use HMR (eligible non-recipients) were sent to pharmacists of which 293 (16%) were returned and met the inclusion criteria. The results showed that most recipients of HMR were very satisfied with the service, had few barriers to using it and were very willing to re-use it. Eligible non-recipients were provided with a description of HMR in the survey and encouragingly, a majority reported that they would be willing to ask for an HMR, if they had concerns about their medicines. Overall however, they were less willing to use HMR than recipients. Having prior awareness of HMR increased eligible non-recipients' willingness to use it. The research reported in Chapter Three used structural equation modelling to analyse the data from a subset of eligible non-recipient consumers (n=286) from Chapter Two who were using multiple medicines (taking more than 5 medicines daily or more than 12 doses daily). Results showed that consumers' willingness to use HMR was most strongly influenced by their positive outcome expectancy - expectations that HMR would provide them with increased medicines knowledge, help them to manage their medicines and reduce their medicine concerns (β = 0.56, P < .001). Importantly however, overall respondents recorded neutral rather than positive or negative scores on the positive outcome expectancy scale. Having determined that consumers' positive outcome expectancy had a strong influence on their willingness to use it, the thesis then focussed on a deeper understanding of the factors which may influence their positive outcome expectancy and willingness to use HMR. The theoretical framework suggested that consumers' worries about experiencing medication- related problems may increase their positive outcome expectancy. Chapter Four reports a qualitative study which was used to explore consumers' expectations of and motivation to use HMR. For this study, 12 focus groups were held using the English language, two in Mandarin and one in Arabic. The data pertaining to recipient (n=28) and non-recipient (n=52) consumers were thematically analysed with the conceptual framework of the study. A key theme was that consumers experienced worries about their medicines. Medicines were considered to be innately harmful and consumers could also experience harm from making mistakes themselves. While some lacked information about their medicines, others believed that medicines information could be confronting. Another theme was that consumers expected that HMR would be useful because they expressed a clear preference to learn about their medicines during interpersonal interactions with pharmacists, rather than from written sources. Consumers' thoughts and feelings appeared to be more focussed on the positive outcomes of HMR when they were worried about medication-related problems. Having demonstrated qualitative support for the hypothesis that increased medication- problem worry would increase positive outcome expectancy and willingness, Chapter Five aimed to test this hypothesis using quantitative methods. In addition, this study aimed to quantify the extent to which willingness was affected by the social influence of the GP - consumers' perceptions of what the GP thinks of HMR. For this study, eligible non-recipient consumers were recruited by postal survey of 1600 members of Council of the Ageing, NSW (COTA, NSW). Surveys received from 390 respondents (24.3%) who were taking multiple medicines were analysed. Similar to the results of Chapter Three, overall respondents recorded neutral rather than positive or negative scores on the positive outcome expectancy scale. Structural equation modelling revealed that consumers' medication-problem worry increased their positive outcome expectancy (β = 0.66, P < .05) and indirectly increased their willingness to use HMR (β = 0.22, P < .05). The effect of the social influence of the GP was to act directly on consumers' willingness to use HMR (β = 0.27, P < .05). The social influence of the GP did not increase positive outcome expectancy. In other words, this social influence was effective, even though it had no bearing over whether consumers thought that the HMR was personally beneficial. Having examined some of the factors influencing consumers' willingness to use HMR, Chapter Six turned to the case of caregivers. The background to Chapter Six identified that caregivers may experience knowledge hassles - daily stressors experienced whilst dealing with tasks which require knowledge about the safety and effectiveness of the care-recipients' medicines. Similar to the effect that medication-problem worry had on consumers' willingness, it was predicted that knowledge hassles would increase caregivers' positive outcome expectancy for HMR and their willingness to assist their care-recipient to use HMR. For this study, a cross sectional postal survey was conducted among members of 2350 Carers (NSW, Australia). Respondents were included in the study if they were involved in medication-related tasks for their care-recipient and were not paid as caregivers. Also, their care-recipient needed to be using multiple medicines and had not yet experienced HMR. There were 324 useable surveys which yielded a response rate of 14%. Structural equation modelling revealed that the higher the level of caregivers' knowledge hassles, the higher their positive outcome expectancy (β = 0.40, P < .05) and since positive outcome expectancy increased willingness (β = 0.55, P < .05), knowledge hassles indirectly increased willingness (β = 0.19, P < .05). Similar to research conducted with consumers (Chapters Three and Five), overall caregivers' positive outcome expectancy was neutral. Conclusion The central aim of this thesis was to investigate the factors which influence consumers' and caregivers' willingness to use HMR, before they have experienced the service. One of the most important findings of the research was that if eligible consumers were informed of HMR they would be willing to ask for it, under the right circumstances. This indicates that consumers have an important role in driving participation in medication management services. Knowledge of the factors which influence willingness to use these services may therefore be used to improve the design and delivery of them with a view to improving consumer acceptance and engagement. In this research, it was demonstrated that a strong influence on consumers' and caregivers' willingness to use HMR was the extent to which they believed that HMR would benefit them personally. In other words a very important influence on willingness was consumers' and caregivers' expectations that during the pharmacist-patient interview they would learn about their medicines, feel reassured, and be more capable managing their medicines. The fact that these expectations were not high yet very influential indicates that there is significant scope for increasing consumers' willingness to use HMR by building th
Author: Stephen Carter
Language: English
Subfield: Geriatrics and Gerontology
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W582348297