The Polypharmacy Challenge Blog
Our research on polypharmacy reveals the burden of work that prescriptions for many drugs create for healthcare professionals and patients. In previous research, we took you behind the scenes of a community pharmacy to show you the work pharmacy staff do to dispense drugs. But polypharmacy creates work for patients too. In our latest paper, we show you the work patients do to organise their many medicines.
Patients in our study took between 10 and 30 different items of medication daily, including tablets, creams, eye drops, injectables, inhalers, and inhaled oxygen. Patients' medicine regimens were complex and needed careful organising as patients strived to take their medicines as prescribed whilst finding ways of fitting them into their daily lives.
Patients often used ‘do-it-yourself’ dosette boxes, tins and bags to organise daily medicine taking. They often set up larger boxes, baskets and storage systems in cupboards to ensure surplus medicines and support processes of checking supplies and ordering. Managing medicines involved considerable resourcefulness, creativity, and collaboration with others.
An important message for doctors is that when patients are prescribed many medicines, work is also prescribed. Whether this work is done by pharmacy staff filling multi-compartment compliance aids (dosettes) or by patients at home with their DIY boxes, bags and trays, the burden of organising polypharmacy always falls somewhere. Greater appreciation amongst prescribers of the nature and complexity of this work may provide a useful point of departure for tackling the key issue that sustains this work: polypharmacy.
Organising polypharmacy: unpacking medicines, unpacking meanings—an ethnographic study by Deborah Swinglehurst and Nina Fudge is published here (open access and free to all to read).
We have a growing number of related research projects looking at multimorbidity and polypharmacy in specific patient groups. Here, Najia Sultan discusses the latest results from her project investigating living with polypharmacy and multimorbidity from the perspective of Urdu-speaking Pakistani Londoners.
As a GP working in an ethnically diverse and deprived area of East London, I regularly witness the particular challenge faced by many of my patients who are living with multiple long-term health conditions. Encouraging patients to self-manage their conditions is seen as the way to address the problem of increasing numbers of people living with multiple long-term conditions. Yet many self-management programmes frequently focus on the individual patient, with little attention paid to the fact that most patients do not exist in isolation. The effectiveness of self-management programs has been questioned, and particularly for ethnic minority groups that are known to carry a disproportionate burden of multimorbidity. There are many social, cultural, and religious factors that play a role in how decisions about health are made.
In this study, I interviewed 15 Pakistani adults (aged 53-87) who spoke Urdu or were bilingual Urdu-English speakers and who had two or more ongoing health conditions. I used the Biographic Narrative Interpretive Method, an open approach to interviewing which invites interviewees to respond to a single question. This resulted in a set of narratives or stories from the interviewees about how they integrated their many ongoing conditions into their lives.
From their stories, I learned how participants framed their health as a matter that is deeply linked to their family and faith.
More specifically, family played a dual role in how the participants managed their long-term health conditions. On one hand, the onset of illness was often attributed to stressful family events such as deaths, difficult marriages, sorrows, and losses. As one participant put it:
“You get ill because there are certain sorrows in life that settle themselves in your heart. And from that, your illnesses keep growing, from thinking about it."
On the other hand, family and friends played a significant role in managing ill health, giving emotional and practical support. However, reliance on family members could also be problematic in some cases: adult children often had a significant say in medical decisions about their parents, even in situations where parents were able to make their own decisions.
Interviewees made many references to their Islamic beliefs, illustrating the importance of spirituality and religious faith in the context of living with and managing ongoing health conditions. Their faith helped them make sense of and cope with deteriorating ill health. This included being grateful for all things — even ill-health:
“Even if I get unwell, well, illness is from God.”
Religious reflection allowed interviewees to speak openly about death and the afterlife. Faith further extended into interviewees' lives as they positioned themselves as ‘good patients’, thankful for the NHS care they have received through God:
“Here, thank God, medicine is free, doctors are free, hospitals are free.”
This study shows that people’s experience of living with multiple ongoing health conditions is at odds with existing health policy, centred on individual choices and autonomous self-management. For them, the self is understood as fundamentally social and committed to God's will. Importantly, this does not mean that participants are less open to medical intervention:
“I ask God for my medicines and my doctors deliver them to me.”
This study has highlighted to me the central importance of understanding individual’s networks of value when caring for their health. This is particularly important within primary care, where an individual will need care over many years for multiple different conditions.
Self-Management in Older Pakistanis Living With Multimorbidity in East London by Najia Sultan and Deborah Swinglehurst. The full paper is available for free here. For those with access to the journal Qualitative Health Research, you can read the paper here.