Study design
This was a qualitative study using in-depth interviews.
Study setting
The study was conducted at the Aga Khan University Hospital - Nairobi (AKUHN). The hospital is a private referral hospital in East Africa that caters mainly for upper and upper-middle-class patients in Kenya. It is a teaching hospital with nine postgraduate medical education programs, including Family Medicine. The hospital offers a wide range of outpatient and inpatient facilities. This study was conducted at the Family Medicine Clinic (FMC) at AKUH-N, a well-established clinic in the hospital with approximately 375 patients in attendance every week. Approximately 20% of the patients attending the FMC are older than 60.
Study population
Inclusion and exclusion criteria
Participants included patients older than 60, who were taking more than five medications per day, capable of communicating in English and Kiswahili, and who had been attending the FMC. Patients with cognitive impairment, such as dementia and psychosis, identified from the medical history in the triage room and those who were too ill were excluded from the study.
Sampling process, sample size and consenting
Participants were recruited using purposive sampling methods. A total of 15 participants were recruited for the study, of whom the initial three interviews were used for piloting purposes. The participants were approached during regular clinic hours at the FMC between 8 am and 4 pm on Mondays and Fridays. During the triage process, the principal investigator, with the help of the triage nurses at the AKUHN, confirmed the age of the patients and enquired about the number of medications taken daily. Those who took more than five medications and fulfilled the inclusion criteria were verbally invited to participate in the study. A study brief was provided verbally during the invitation process and explained in simple English or Swahili (Language was as per the patient's preference). If the patient agreed to participate, they were invited to provide written consent. A mutually convenient time was decided upon for the interview, either at the same sitting or later at the FMC, AKUHN.
During the interview, the researcher explained the study information focusing on the purpose, the benefits, possible risks and a confidentiality clause. Participants read the consent forms, and those who agreed to participate in the study provided written consent.
The participants were then allowed to ask any questions that may have arisen.
Data collection
MK (the lead researcher) conducted interviews after undergoing training and familiarizing herself with the interview guide. Interviews were conducted at the FMC at a time convenient and acceptable for the participants in one of the offices. Informed consent procedures were carried out at the start of each interview, and participants were given ample opportunity to make any inquiries before the interview commenced. Participants were also reminded of willful withdrawal.
An open-ended and flexible topic guide encouraged free-flowing dialog with participants. The interviews were in English or Kiswahili (language choice was based on participants' preference) and audio-recorded with participants' verbal and written consent. Two interviews were conducted in Swahili, and the rest were conducted in English; therefore, translation to English was performed for the two interviews before transcription. Field notes were also taken during the interview process.
The study tool was piloted by MK on three participants, transcribed and reviewed by AL, GM and NN (all of whom were co-investigators). Challenges such as older people's understanding of various terminologies were discussed. The team agreed that during the interview, a wide range of prompts and synonyms would give the participants more time to help them delve into their feelings. Topic guides were thematically designed to include perceptions and influence of polypharmacy, knowledge and sources of information, attitudes, beliefs, barriers and coping strategies. Participants were interviewed once after signing written informed consent. At the end of each interview, a debriefing statement was read to all the participants.
The study was conducted in the context of COVID-19. All precautions, such as social distancing, wearing face masks, and hand and surface sanitization, were strictly followed.
Participants were asked questions about their knowledge and understanding of polypharmacy, beliefs, storage and attitudes towards the medication.
Interviews were audio recorded, carefully labelled and transferred to a secured laptop. Interviews conducted in Swahili were translated from Kiswahili to English, and all interviews were transcribed. GM and NN validated transcripts by listening to the audio and translated narratives. A unique participant study identification (PTID) was allocated to participants to identify participant study records.
Data analysis
A thematic analysis process was undertaken using Braun and Clarke in 2006 a six-approach (16). Researchers familiarized themselves with the data and generated the initial codes by dividing data into small meaningful chunks. All the authors reviewed the codes, and developed a codebook. Researchers frequently met to discuss the data by creating a matrix that mapped all the themes below. Member checking was done, where research findings were summarized, and transcripts were shared with the participants to verify the data.