The experiences and beliefs of older people in Scottish very sheltered housing about using multi-compartment compliance aids
International Journal of Clinical Pharmacy
The experiences and beliefs of older people in Scottish very sheltered housing about using multi‑compartment compliance aids
Derek Stewart 0 1
Kathrine Gibson Smith 0 1
Joan MacLeod 0 1
Alison Strath 0 1
Vibhu Paudyal 0 1
Katrina Forbes‑McKay 0 1
Scott Cunningham 0 1
Katie MacLure 0 1
0 University of Birmingham , Birmingham, England , UK
1 Robert Gordon University , Aberdeen, Scotland , UK
2 Derek Stewart
Background Multi-compartment compliance aids (MCAs) are promoted as a potential solution to medicines non-adherence despite the absence of high quality evidence of effectiveness of MCA use impacting medicines adherence or any clinical outcomes. Furthermore, there is a lack of qualitative research which focuses on the perspectives of older people receiving MCAs. Objectives To describe experiences and beliefs surrounding very sheltered housing (VSH) residents' use of MCAs with emphasis on issues of personalisation, reablement, shared decision-making, independence and support. Setting VSH in north east Scotland. Methods Qualitative, face-to-face interviews with 20 residents (≥ 65 years, using MCA > 6 months) in three VSH complexes. Interviews 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. Interviews were audiorecorded, transcribed and analysed using a framework approach. Main outcome measure Experiences and beliefs surrounding use of MCAs. Results Nine themes were identified: shared decision-making; independence; knowledge and awareness of why MCA had been commenced; support in medicines taking; knowledge and awareness of medicines; competent and capable to manage medicines; social aspects of carers supporting MCA use; benefits of MCAs; and drawbacks. Conclusion Experiences and beliefs are diverse and highly individual, with themes identified aligning to key strategies and policies of the Scottish Government, and other developed countries around the world, specifically personalisation shared decision making, independence, reablement and support.
Ageing; Behavioural medicine; Geriatrics; Patient adherence; Patient education; Primary care; Scotland
• Given that the experiences and beliefs surrounding the
use of MCAs by elderly are diverse and highly
individual, focus should be placed on a person centred approach
• Health and social care professionals involved in aspects
of the supply of MCAs should consider issues of
personalisation, shared decision-making, independence,
reablement and support.
The World Health Organization (WHO) World Report on
Ageing and Health highlights that globally, the number and
proportion of older people is increasing markedly [
Scotland, the number of people 65 years and over is
estimated to increase by 53% between 2014 and 2039 [
2009, the Scottish Government Ministerial Strategic Group
for Health and Wellbeing developed a strategy,
Reshaping Care for Older People, with the goal to ‘optimise the
independence and wellbeing of older people at home or in
a homely setting’ [
]. The strategy places much emphasis
on a health and social care shift towards ‘personalisation’,
whereby people become more involved in how services are
designed and receive the support that is most suited to them.
More recently, the focus for the support of older people has
been based on ‘reablement’, to assist older people to learn
or relearn those skills needed for a successful and fulfilling
Personalisation, reablement, shared decision-making,
independence and support may be viewed in the context
of Self Determination Theory (SDT), a theory of
motivation and human behaviour [
]. SDT outlines three key
constructs which are considered intrinsic psychological needs
and which contribute to enhanced wellbeing: competence,
autonomy, and relatedness. Autonomy refers to a need to feel
volitional and responsible for the execution of a behaviour;
competence concerns the need for individuals to feel
effective in interactions with their environment; and relatedness,
the need to feel a sense of belongingness and connectedness
with others. The theory further highlights the importance
of the role of the social environment in fostering the three
psychological needs [
These principles of personalisation, reablement, shared
decision-making, independence and support are of direct
relevance to the use of medicines in older people [
particularly given the extent of medicines use in this
population. Multimorbidity, defined as ‘the co-occurrence of
two or more chronic medical conditions in one person’, is
highly prevalent in older people, increasing rapidly with age
in terms of both prevalence and the number of morbidities
. Increases in multimorbidity in older people are
mirrored by the increasing numbers of prescribed medicines, as
evidenced from data published in the United Kingdom (UK)
], United States , and Europe [
Medicines non-adherence is one potential consequence of
the increasing medicines burden in multimorbid older people
], with data suggesting that between 50 and 80% of
those with chronic conditions may be non-adherent .
A number of interventions have been proposed as
potential solutions to non-adherence in older people [
Multi-compartment compliance aids (MCAs), also referred
to as Monitored Dosage Systems and Dose Administration
Aids, are repackaging systems for solid dosage form
medicines, such as tablets and capsules, where the medicines
are removed from manufacturer’s original packaging and
repackaged into the MCA . While these are promoted as
a potential solution to non-adherence, the Royal
Pharmaceutical Society has expressed concern that pharmacy supplied
MCAs have ‘become regarded as a panacea for medicines
use and often integrated into practice and service policy
without giving due consideration to the alternatives’ [
Systematic reviews published in 2011 and in 2016
highlighted the lack of evidence of effectiveness of MCA
use impacting medicines adherence or any of the clinical
outcomes studied [
]. In addition, MCA use in older
people may be linked to reduced medicines related
knowledge, thought to be due to not recognising the different
medicines within the MCA . To date there is a dearth
of research which has focused on the perspectives of older
people receiving MCAs. One study of older people living
independently and an unrelated sample of health
professionals involved in MCA provision identified mixed views on
whether MCAs helped or hindered in maintaining
independence and control over medicines [
Given the predictions of increased numbers of older
people globally, the extent of medicines use, the potential for
non-adherence and consequent MCA use, there is a need
to ensure that older people are involved in any decision to
commence an MCA. Ideally that decision should also be
centred on the principles of personalisation, reablement,
shared decision-making and independence.
We recently reported a case study of older people
provided with MCAs, their carers and health professionals, the
aim of which was to explore the factors influencing MCA
]. Goals of use related to promoting adherence and
safety, with less emphasis on independence. Beliefs of
consequences related to these goals were considered of value,
with additional consequences of concern around reduced
awareness of medicines and complexities of changing
medicines. In this paper, we focus on the perspectives of the older
Aim of the study
The aim was to describe the experiences and beliefs of
older people surrounding the use of MCAs, with emphasis
on issues of personalisation, reablement, shared
decisionmaking, independence and support.
This study was approved by the National Health Service
(NHS) North of Scotland Research Ethical Review Service
(14/NW/1168) and NHS Grampian Research and
Development Committee (2014RG002).
This was a qualitative study comprising individual
face-toface 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.
Inclusion and exclusion criteria
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
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).
Unaware of what medicines are prescribed for “Furosemide was that ein [one]. Da ken [I don’t
know] what it’s for” Case 4 at K
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
Knowledge and awareness of why MCA commenced
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)
Support in medicines taking
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)
Competent and capable to manage medicines
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
…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)
Social aspects of carers supporting MCA use
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)
Benefits of MCAs
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)
Drawbacks of MCAs
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)
This study has provided an in-depth description of the
perspectives of residents of VSH surrounding their experiences
and beliefs of using MCAs. Nine key themes were
identified: shared decision-making; independence; knowledge and
awareness of why the MCA had been commenced; support
in medicines taking; knowledge and awareness of medicines;
competent and capable to manage medicines; social aspects
of carers supporting MCA use; benefits of MCAs; and
drawbacks of MCAs. There were many examples of diverse, and
often polarised, experiences and beliefs within each theme.
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 [
]. 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 [
]. It may
be beneficial for pharmacists and pharmacy staff to explore
patient issues around MCA us in an effort to promote shared
The issue of non-adherence in those with chronic
conditions is widely acknowledged [
]. 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
]. While systematic reviews have failed to
demonstrate objectively that MCAs improve adherence [
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 [
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 [
Strengths and weaknesses
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
]. 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
The experiences and beliefs around MCA use in older
people are diverse and highly individual. The themes
identified aligned with key strategies and policies of the Scottish
Government, specifically personalisation shared
decisionmaking, independence, reablement and support.
Acknowledgements The research team gratefully acknowledge all
research participants, Rory Lynch for comments on study design and
Jeanette Lowe for transcribing all the interviews.
Funding This work was supported by research funding from Aberdeen
City Community Health Partnership. The funder who played no role
in the design, execution, analysis and interpretation of data, or writing
of the study.
Conflicts of interest The authors have no conflicts of interest to
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