ORIGINAL ARTICLE

Exploring motivation and confidence in taking prescribed medicines

in coexisting diseases: a qualitative study

Allison Williams and Elizabeth Manias

Aims and objectives. To explore the motivation and confidence of people with coexisting diabetes, chronic kidney disease

(CKD) and hypertension to take their medicines as prescribed.

Background. These comorbidities are major contributors to disease burden globally. Self-management of individuals with

these coexisting diseases is much more complicated than that of those with single diseases and is critical for improved health

outcomes.

Design. Motivational interviewing telephone calls were made with participants with coexisting diabetes, CKD and hyper-

tension.

Methods. Patients aged � 18 years with diabetes, CKD and systolic hypertension were recruited from outpatient clinics of

an Australian metropolitan hospital between 2008–2009. An average of four motivational interviewing telephone calls was

made with participants (n = 39) in the intervention arm of a randomised controlled trial. Data were thematically analysed

using the modified Health Belief Model as a framework.

Results. Participants’ motivation and confidence in taking prescribed medicines was thwarted by complex medicine regimens

and medical conditions. Participants wanted control over their health and developed various strategies to confront threats to

health. The perceived barriers of taking recommended health action outweighed the benefits of taking medicines as pre-

scribed and were primarily related to copious amounts of medicines.

Conclusion. Taking multiple prescribed medicines in coexisting diabetes, CKD and hypertension is a perpetual vocation with

major psychosocial effects. Participants were overwhelmed by the number of medicines that they were required to take. The

quest for personal control of health, fear of the future and the role of stress and gender in chronic disease management have been

highlighted. Participants require supportive emotional interventions to self-manage their multiple medicines on a daily basis.

Relevance to clinical practice. Reducing the complexity of medicine regimens in coexisting diseases is paramount. Individua-

lised psychosocial approaches that address the emotional needs of patients with regular follow-up and feedback are neces-

sary for optimal chronic disease self-management.

Key words: comorbidities, diabetes, emotional support, hypertension, kidney disease, medication adherence, motivational

interviewing, self-management

Accepted for publication: 31 October 2012

Introduction

The comorbidities of diabetes, chronic kidney disease

(CKD) and cardiovascular diseases, specifically hyperten-

sion, are increasing in prevalence as population ages

(Sowers et al. 2001, Tong & Stevenson 2007). Self-man-

agement of these coexisting diseases is much more

complicated than that of single diseases, and appropriate

self-management is critical for improved health outcomes

(Bakris 2004).

Authors: Allison Williams, PhD, Associate Professor, School of

Nursing and Midwifery, Monash University Health Sciences,

Frankston, Vic.; Elizabeth Manias, PhD, Professor, School of

Health Sciences, The University of Melbourne, Carlton, Vic., Aus-

tralia

Correspondence: Allison Williams, Associate Professor/Campus

Head, School of Nursing and Midwifery, Faculty of Medicine,

Nursing and Health Sciences, Monash University, PO Box 527,

Frankston, Vic. 3199, Australia. Telephone: +61 3 9904 4377.

E-mail: allison.williams@monash.edu

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, doi: 10.1111/jocn.12171 1

Background

Adherence can be defined as the extent to which patients

follow the instructions they are given for prescribed treat-

ments: approximately 50% of patients do not take their

medicines as prescribed, and this risk increases as the num-

ber of prescribed medicines increases (Haynes et al. 2008).

A USA study of nearly two million older people with diabe-

tes and CVD showed estimated nonadherence rates for

oral hypoglycaemic agents, angiotensin-converting enzyme

inhibitors, angiotensin II receptor blockers and statin medi-

cines of 35, 42, 46 and 35%, respectively (p < 0�001)(Yang et al. 2009). With the addition of CKD, medicine

nonadherence rates are likely to be higher. Globally, medi-

cine-related morbidity has accounted for 4�3% of prevent-

able hospital admissions (Winterstein et al. 2003).

While pharmaceutical developments in chronic disease

management are extensive, innovations to help patients fol-

low medicine prescriptions in the presence of coexisting

chronic conditions have rarely been examined. Educational

chronic disease self-management programmes have prolifer-

ated in recent years, but their efficacy over the long term

has been questioned (Newman et al. 2004, Swerrisen et al.

2006, Khunti et al. 2012). Person-centred strategies, such

as coaching (Vale et al. 2003, Young et al. 2007), and

motivational interviewing (Rueda et al. 2009) have the

potential to detect patients’ concerns in managing their

medicines and therefore have the propensity to identify

helpful strategies for chronic disease self-management.

We developed a patient-centred intervention to improve

medicine adherence in people with diabetes, CKD and

hypertension (Williams et al. 2012). The present study

reports participants’ responses to the motivational inter-

viewing aspect of the intervention. The aim of this study

was to explore the motivation and confidence of people with

coexisting diabetes, CKD and hypertension to take their

medicines as prescribed over the course of the intervention.

Methods

Design

Telephone calls using a motivational interviewing approach

were made with participants with coexisting diabetes, CKD

and hypertension in the intervention arm of a randomised

controlled trial. The protocol of the multifactorial interven-

tion has been reported elsewhere (Williams et al. 2010).

Patients aged � 18 years with type 1 or type 2 diabetes,

stage 2–4 CKD [Modified Diet in Renal Disease glomerular fil-

tration rate (eGFR) >15–� 60 ml/min/1�73 m2] and systolic

hypertension � 130 mmHg were recruited from nephrology

and diabetes outpatient clinics of an Australian metropolitan

hospital. Thirty-nine participants were randomly allocated to

the intervention group.

Data collection

Demographic and medical data were collected on enrol-

ment to the study. Motivational interviewing telephone

calls were made fortnightly by the intervention nurse for a

period of 12 weeks following the intervention home visit.

Motivational interviewing is a person-centred counselling

method for enhancing intrinsic motivation to change by

exploring and resolving ambivalence (Miller & Rollnick

2002). The intervention nurse was trained in motivational

interviewing and observed the principles of expressing

empathy, developing discrepancy, avoiding argument and

supporting self-efficacy in the calls (Miller & Rollnick

2002, Dilorio et al. 2003). Each call followed a semi-struc-

tured adherence counselling script (Table 1), which was

adhered to for fidelity purposes.

The first call familiarised the participant with the motiva-

tional interview schedule and established the pattern for

following calls. Each call followed a similar format and

incorporated suggestions or queries made in previous calls.

The intervention nurse took comprehensive handwritten

Table 1 Motivational interviewing schedule

The script comprised sequential questions, commencing with

an open-ended question enquiring about participants’ well-being

An enquiry about participants’ blood pressure and medicines

followed, such as whether any changes were made to their

medicines, whether they have experienced any difficulties taking

their medicines and whether they have any concerns regarding

their health

Participants were then asked to score their motivation and

confidence with taking all of their medicines as prescribed from

1–10, with a higher score being more favourable

The participant’s responses to these questions (e.g. ‘Why did you

not choose a lower/higher number?’) were used to explore

uncertainties about taking medicines as prescribed using positive

self-motivational statements to encourage self-efficacy

A summary of the ‘pros and cons’ of these comments was

presented back to the participant, inviting suggestions and

discussion of strategies that have worked for other people to

enhance behavioural change

Participants were then asked to identify three life goals to expose

any areas of ambivalence between these goals and their current

behaviour

Before concluding the call, key points were summarised, desirable

behaviour was affirmed and a request for the participant to try

at least one strategy to enhance positive behavioural change was

made

© 2013 John Wiley & Sons Ltd

2 Journal of Clinical Nursing

A Williams and E Manias

notes during each call to capture what participants said,

including short sentences and phrases which formed the data

set. Each call was incorporated into the analysis because of

the variety of responses between all of the participants and

between each participant at every time point. Participants

were aware that the intervention nurse was taking notes and

were sometimes asked to repeat statements to clarify medi-

cine names and enable notation. The notes were transcribed

after each call as soon as possible for clarification and to

maximise recall of information prior to importing the

data into NVIVO®, version 8 (QSR International, Melbourne,

Victoria, Australia), which was used to process the data.

Data analysis

Data were analysed using a thematic approach (Ritchie &

Spencer 1994), incorporating the modified Health Belief

Model (HBM; Rosenstock 1974, Becker 1976) as a frame-

work. The model assumes that people will follow pre-

scribed treatments if they believe that doing so will avoid

negative health outcomes, and that they have the self-

efficacy to follow treatments. People’s ‘readiness to act’ is

dependent on their perceived susceptibility to a particular

health problem, their perceived severity of the health prob-

lem, the benefits and barriers to taking positive health-

related action and self-efficacy (Glanz et al. 2002).

All transcripts were examined independently by two

investigators, and emerging subthematic patterns of analy-

ses were compared and scrutinised to reduce researcher

bias. Both investigators examined the final analysis for

agreement, consistency and valid interpretation.

Prior to commencing the study, ethics approval was

obtained from the ethics committees of the participating

hospital and university. Written informed consent was

obtained from participants prior to enrolment. The study

was conducted under the ethical guidelines of the National

Health and Medical Research Council of Australia (2007).

Results

The demographic characteristics of the 39 participants are

shown in Table 2. The intervention nurse made a total of

164 motivational interviewing calls (an average of four calls

per participant) totalling 19�4 hours (25,781 words)

between October 2008–August 2009. A median of seven

calls (range, 4–14) was made to each participant in an

effort to reach them every fortnight before the intervention

was completed at 12 weeks postbaseline.

The median length of each motivational interviewing call

was 11�75 minutes (range, 2–29 minutes), and the last calls

were generally shorter. Three participants were difficult to

contact: two participants claimed to have problems with

their home telephone lines and/or hung up and one partici-

pant did not have a private telephone whereby the costs of

the calls were provided to enable him to call at prearranged

times using a public telephone. Participants rated their

motivation between 1–10 in taking their medicines as pre-

scribed, which ranged from 5�5–10 (median 10), and their

confidence in taking their medicines as prescribed ranged

from 5–10 (median 10). Two participants were unable to

rate their motivation and confidence despite prompting.

Transcribed data produced 749 free nodes, which were

organised into themes of complex health problems, active

self-management, trying to self-manage and discontent of

the medical model of care. These themes and their subthe-

mes were then mapped to the motivational categories and

their components within the modified HBM (Rosenstock

1974, Becker 1976) (Table 3).

Table 2 Self-reported baseline characteristics of participants

(n = 39)

n (%)

Age, mean (SD)* 68�0 (8�3)Female 17 (43�6)Country of birth

Australia 14 (35�9)Italy 9 (23�1)Other 16 (41�0)

English proficiency level

Not well 1 (2�6)Well 8 (20�5)Very well 30 (76�9)

Support person at home 36 (92�3)Smoker 10 (25�6)Regular alcohol consumption (>weekly) 16 (41�0)Regular exercise (30 minutes walk three times

a week)

18 (46�2)

Blood pressure mean(SD)

Systolic 151�2 (14�5)Diastolic 76�3 (10�7)

Number of prescribed medicines mean(SD),

range taken each day*†7�6 (2�6) (1–10)

How long diagnosed with diabetes, years 18�6 (13�4)‡How long diagnosed with kidney disease, years 7�6 (7�4)§Number of other chronic illnesses mean (SD)* 7�7 (2�5)

*Age, number of prescribed medications and chronic illnesses as

indicated by Student’s t-test (all others indicated by Fisher’s exact

test).†The RCT used pill counts as a measure of medicine adherence and

insulin, and over-the-counter medications were not included in this

number.‡Median 18, IQR (6–25).§Median 4�5, IQR (2�5–10�5).

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing 3

Original article Motivation and confidence in multiple medicine use

Individual perceptions

Importance of health

Wanting control of health. Individual perceptions that pre-

disposed participants to embrace positive health behaviour

related to how important they regarded health and a desire

to control their health. Such control related to their blood

pressure, blood glucose and weight:

Legs still bad – wish I had control over legs like I have over

diabetes. (Code 89, contact 5)

Alters medicine prescriptions. The most common

way these participants attempted to have control of

their health was by altering prescriptions. Most partici-

pants had limited health literacy and were unclear about

their complex health states and the purpose of their

medicines. Nevertheless, participants experimented with

their medicines without their doctors’ knowledge in an

attempt to control their health, placing medicine safety at

risk:

I experiment with tablets. I swap Diamicron [gliclazide] 80 with

Diamicron 30 MR every day. Trying to work them out… fiddle

with them… I manage medicines myself… take them when I think.

(Code 103, contact 1)

Use of complementary and alternative medicines

(CAMs). Participants attempted to have control of their

health by initiating the use of complementary medicines

such as fish oils, vitamin D and irritable bowel syndrome

support-medicine:

Will cease Ginko when finished as expensive. Trying OTCs [over

the counter medicines] to see if they make a difference [to my

health]. (Code 52, contact 1)

Perceived seriousness of disease

Thinking about mortality. Participants’ perceptions of the

seriousness of disease consisted of thinking about mortality.

Dying was a recurring theme throughout motivational

interviewing. The life goals that participants identified

almost unanimously pertained to staying alive. Three par-

ticipants had medical problems that they considered were

not going to kill them ‘just yet’:

When I have hypos [hypoglycaemia] on my own, I never know if

I will come out of it. I should be dead quite a few times. (Code

81, call 1)

Comorbidities complicate treatment. Nine participants

talked about how their other comorbidities interfered with

Table 3 Thematic analysis of motivational interviewing calls using the modified Health Belief Model (Rosenstock 1974, Becker 1976)

Individual perceptions Modifying factors Likelihood of action

Importance of health

Wanting control of health

Alters medicine prescriptions

Use of complementary and alternative

medicines

Demographic and psychosocial aspects

CALD influences

Family problems

Lack of resources

Perceived benefits of acting

Valuing medicines

Perceived seriousness of disease

Thinking about mortality

Comorbidities complicate treatment

Acute illnesses risk health

Interpersonal aspects

Partnerships with health professionals

Negotiating the healthcare maze

Difficulties with continuity of care

Perceived barriers to act

Cost of medicines

Too many medicines

No symptoms

Medicine side effects

Forgetting medicines

Actively resisting medicines

Wary of changes to medicines

Uninformed about health matters

Questioning the benefit of medicines

Targets unrealistic

Perceived threat of disease

Wishing and hoping

Denial – a cavalier approach

Looking to blame

Que sera sera

Cues to action

Learnt from prior experience

Seeking information

Self-efficacy

Positive feedback

Importance of a positive approach –

mind over matter

Likelihood of taking action

Having a supply of medicines

Support from family

Medicine reminders and routine

CALD, culturally and linguistically diverse.

© 2013 John Wiley & Sons Ltd

4 Journal of Clinical Nursing

A Williams and E Manias

treatment options. For example, two participants reported

that prescribed medicines to correct one condition were

contraindicated by another. A participant with coexisting

liver disease stated:

Scared now to take iron [ferrous sulphate] tablets. They tried to

fix me up in one way and trying to kill me in another way [iron

overload]. (Code 102, contact 6)

Acute illnesses risk health. The difficulty in managing

multiple chronic illnesses was compounded when partici-

pants became acutely ill. Often, more medicines were

needed in addition to usual medicine regimens, requiring

another doctor’s visit and prescription fill:

Unable to get to the ‘phone-in bed with ‘gastro’ [gastroenteritis]

for three days. Blood pressure was high but now it has come

down. Had a very bitter taste in my mouth – was able to take

tablets – in bed for a few days – was dizzy – maybe blood pressure

was low. I couldn’t take my blood pressure when sick – it is 138/

82 today. Was too sick to have bloods taken for Hospital A clinic

coming next Wednesday. (Code 1, contact 2)

Perceived threat of disease

Wishing and hoping. Participants’ perceived threat of dis-

ease entailed wishing and hoping not to become sicker

than what they already were and looking for cures to

‘get rid of tablets’ (Code 27). Two participants enrolled

in a clinical trial in the hope of receiving a new medicine

that would control their blood pressure. Participants

wished that they had known more about the importance

of good disease control earlier on in their lives

before complications had developed, leading to feelings of

regret:

I wasn’t aware of [the dangers of] blood pressure earlier and if

I was, it would have been different. (Code 1, contact 1)

Denial – a cavalier approach. Not wanting to know

about health and denial were common features of the moti-

vational interviewing calls. Three participants did not have

functioning glucometers to test their blood glucose to direct

medicine doses. Participants commented that if they felt

reasonable within themselves, they were not overly con-

cerned about poor clinical manifestations such as high

blood pressure:

Blood pressure is 201 [systolic] – I am not overly concerned – I feel

OK. Not much point getting upset about it if I feel OK – 201 [sys-

tolic] is better than 210. Has been as low as 160/68 – I don’t know

– if it’s below 200, I feel like I have achieved something. It’s not

always high. I didn’t do anything different. (Code 16, contact 5)

Most of the participants talked about uncomfortable

symptoms dominating their health concerns, such as fati-

gue, poor vision, arthritic pain, respiratory problems and

itchy skin:

Blood pressure is alright – ‘thrush’ [vaginal candida albicans] drives

me crazy. The cream made it worse. I am still on [hormonal]

patches and have hot flushes. Could be stress, doctor says – daugh-

ter says I’m always stressed. (Code 25, contact 4)

Looking to blame: Participants searched for reasons as to

why they became ill:

Had a glucometer for 12 years before I got diabetes so that is why

I think Avapro HCT [irbesartan plus hydrochlorothiazide] caused

my diabetes – [diabetes] not in my family but I wanted to see what

my health was and then found my blood sugar 14 (mmol/L) at the

local doctors. Not a coincidence! (Code 42, contact 2)

Que sera sera. Despite wanting to be free of disease, par-

ticipants (n = 8) felt powerless to change their future and

enjoyed what life they had left to enjoy:

Whatever happens, happens – I wish I wasn’t a diabetic, have high

blood pressure, headaches, dizzy – have more confidence and

independence – be free, go to the shops. (Code 75, contact 2)

Modifying factors

Demographic and psychosocial aspects

CALD influences. The most important demographic factor

affecting motivation to take recommended health action

was whether the participant’s first language was English.

Twenty-three participants came from nonEnglish-speaking

backgrounds, placing health literacy and trust necessary for

optimal chronic disease self-management at risk. In prefer-

ence to using a hospital interpreter, participants came to the

clinic with family members who spoke English, or they found

doctors who spoke their language, resulting in additional

doctors providing care, which could lead to further problems:

I am not really very good – I still cough – he [doctor] says I have

asthma-sensitive chest and lungs – especially these tablets [perindo-

pril]. Blood test yesterday with new doctor – two bus trips and

walk. Went yesterday before it got hot… Hungarian Doctor –

[speaks] my language. (Code 62, contact 4)

Family problems. Female participants most often wanted

to talk about psychosocial concerns and emphasised ‘trying’

to take their medicines all the time. Some participants

(n = 7) had family obligations, such as caring for parents

and grandchildren, which contributed to difficulties with

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing 5

Original article Motivation and confidence in multiple medicine use

self-management. Spouses often took on the role of admin-

istering medicines to lessen the stress of medicine adher-

ence. Some participants’ spouses knew more about

participants’ health than the participants themselves, who

preferred to take a passive role in managing their own

health. Alternatively, some partners worried about their

spouses’ approaches to their own health, where taking

medicines as prescribed or following doctor’s orders created

sources of conflict in the relationship:

Conflict with wife – she is disinterested and thinks I am obsessed

with my health. (Code 32, contact 1)

Becoming older was accompanied by loneliness, which

provided minimal incentive to take medicines as prescribed:

Watching TV – just me and the four walls and the TV – every day

is the same. (Code 91, contact 3)

Lack of resources. An important demographic aspect

influencing motivation and confidence to take medicines as

prescribed was a lack of resources. Limited or delays in

follow-up medical appointments and restrictions on equip-

ment, such as insulin pumps, led participants to worrying

about their deteriorating health:

Refused an insulin pump – “only for young people.” Every time I

go I start to get sick about it. They say, “I’m the doctor, not you.”

What can I do? I can’t try another doctor – [I’m in the] public health

care system. Insulin device is $6000–7000. (Code 102, contact 6)

Interpersonal aspects

Partnerships with health professionals. Interpersonal aspects

affecting motivation to take medicine as prescribed included

the critical partnership between the participant and the

healthcare provider. A few participants (n = 5) monitored

their health closely and enjoyed ‘nondictatorial’ partner-

ships with their general practitioners who they could talk

to, trusted and discussed their treatment. A participant who

instigated taking his medicines at different times of the day,

contrary to his prescription, stated:

No one is very happy with my pill change. My substitute GP

[general practitioner] is not happy. “Do it our way, we know

best.” I said, “Here’s the paper, here’s the [self-monitored blood

pressure] readings.” My GP said, “Oh, I wonder why?” I said,

“My way is working – which way should we go?” GP said, “Go

your way.” (Code 64, contact 4)

Navigating the healthcare maze. Navigating the health-

care system came with experience and a certain amount of

distrust. A lack of sensitive communication and partner-

ships between participants and the healthcare provider led

to participants to abandon health advice and ongoing refer-

rals or to submit fabricated health tests, for example ideal

blood glucose readings, so as not to be “ticked off by the

doctor.” (Code 89):

The general practitioner is for scripts only – no more than that –

he will not alter blood pressure medicines – must be at the

outpatient’s clinic. I don’t ask the pharmacy much – specialists are

my first line of knowledge. (Code 108, contact 1)

Difficulties with continuity of care. There were 20

instances relating to dissatisfaction with the quality of care

provided in the specialist outpatient clinics, affecting medi-

cine self-management. Two participants reported that if

they were not compliant with the clinic doctors’ orders, the

clinic doctors would not see them. Importantly, communi-

cation was hampered by a lack of continuity of care:

Gets mixed messages from doctors. Always different doctors in

diabetes and kidney clinics. (Code 62, contact 4)

Cues to action

Learnt from prior experience. All participants had learnt

from prior experiences that medicines had kept them alive

or had helped them to feel better when symptomatic.

Following healthy practices was also seen as advantageous:

Back on tablets and water pills and have seen GP [general practi-

tioner] – I’m feeling better. The last few days I’m back in full swing

with the tablets. One week I didn’t take any tablets. GP said I was

a naughty girl. (Code 21, contact 6)

Five participants had family members who were on dial-

ysis or had lost limbs from diabetes, a blatant reminder of

the consequences of poor disease control. One participant

was already confined to a wheelchair as an amputee. Par-

ticipants had learnt that if they complained, they drew

attention to themselves when all they wanted was to be

seen as normal:

Have many problems… can’t expect for everything to be normal at

my age. Remains motivated – it is the only thing that will help me.

(Code 1, contact 3)

Seeking information. Thirteen participants (nine men)

used information and advice from their general practitioner

and the Internet to make decisions regarding their medi-

cines. Four of these participants had concerns about high

potassium levels as a result of kidney damage, demonstrat-

ing an advanced understanding of medical information:

Avapro [irbesartan] not HCT [irbesartan plus hydrochlorothiazide]

anymore. Took my blood pressure readings to the doctor and he

© 2013 John Wiley & Sons Ltd

6 Journal of Clinical Nursing

A Williams and E Manias

changed my meds [medicines] – off HCT because of potassium

research. (Code 42, contact 3)

Self-efficacy. Self-efficacy was a large component of cues

to take medicines as prescribed. Nearly all participants were

curious about their health and wanted to be well informed

and to participate in decisions regarding their care:

Breakfast automatic – pills and blood pressure – 67 years on insu-

lin. Start the increased dose of Coversyl [perindopril] today. The

only thing I have to watch out for is high potassium – it has been

6 [mmol/L]. (Code 43, contact 1)

Positive feedback. Self-efficacy was enhanced by positive

feedback, which reinforced good behaviour. Thirteen par-

ticipants reported being ‘pleased’ with good health reports,

which, in one case, initiated calling a sibling to share the

good news:

Blood pressure today was 130/70 at the doctors – I can’t believe

it – too perfect! Went and topped up scripts. (Code 3, contact 5)

Having illnesses for many years made participants critical

of health information and not wanting to ‘chop and

change’ (Code 64) their treatment:

My General Practitioner [GP] changed spiractin [spironolactone]

25 mg/day to 100 mg/day yesterday and I will start tomorrow. If I

find something wrong, I will stop it. I don’t trust GP entirely – I

like to have control. I will take it to show if there is any difference.

(Code 108, contact 4)

Importance of a positive approach – mind over matter.

An optimistic view enabled coping, which facilitated the

management of complex medicine regimens. Four

participants stated that they had no trouble taking their

medicines, where one participant stated he ‘could take 20,

no problem’ (Code 3).

Likelihood of taking positive health action

Perceived benefits of acting

Valuing medicines. The perceived benefits of taking medi-

cines related to how participants valued their medicines and

the perceived consequences of not being adherent, such as

being ‘scared not to take tablets’ (Code 88). Participants

prioritised which medicines were absolutely necessary for

their health. This necessity was dependent on the apparent

ability of the medicine to treat the condition or the conse-

quences of not taking the medicine:

Take all the medicines that I need – just not statin and aspirin –

and only take half coversyl [perindopril] as it makes me dizzy.

Prefer ramipril. Once finished coversyl, I will go back on ramipril.

(Code 62, contact 1)

Perceived barriers to act

The perceived barriers of taking medicines as prescribed

was the largest subtheme in the analysis, clearly overriding

the benefits of taking medicines as prescribed, and was

primarily related to copious amounts of medicines.

Cost of medicines. Prolific use of medicines was an added

expense for people and detrimental to quality of life, which

deterred medicine adherence. Some prescriptions provided

only 28-day supply of medicines for a calendar month. Dou-

ble-strength medicines were a way of saving on prescription

medicines by having two doses in one tablet, but some par-

ticipants reported doctors were reluctant to prescribe them:

Spends $1400 until the safety net starts [Australian Government

Pharmaceutical Benefits Scheme threshold which enables medicines

to be purchased at less cost] – gets there in November now – it

used to be July. (Code 34, contact 1)

Information provided by the public hospital system

assisted patients to buy cheaper medicines, some of which

were through the hospital pharmacy.

Too many medicines. Keeping a constant supply of medi-

cines was difficult: prescriptions were lost or expired,

requiring another doctor appointment, and pharmacies did

not always stock particular medicines. Participants avoided

further medicines by not disclosing all their health problems

in medical consultations:

Dizzy – blood pressure, I suppose. Tablets, I suppose. Nearly live

at the doctors. (Code 21, contact 1)

No symptoms. The absence of symptoms provided little

incentive for people to take their medicines:

No symptoms is the problem – I never feel any different or feel

anything. Have symptoms when blood sugar low but >12–13

[mmol/L], don’t feel any different. (Code 3, contact 3)

Medicine side effects. The most common reason for par-

ticipants to stop taking their medicines was unpleasant side

effects that included hair loss, weight gain, urinary reten-

tion, fluid retention, blurred vision, diarrhoea and vomiting,

rashes, and pulmonary oedema:

Ranatidine caused headaches, tiredness and sore knees so I don’t

take it. (Code 88, contact 1)

Participants felt doctors were inclined to think side

effects were not from medicines, but ‘due to something

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing 7

Original article Motivation and confidence in multiple medicine use

else’, so that their patients would continue to take the med-

icine (Code 39).

Forgetting medicines. Despite participants’ assurances of

taking medicines all the time, there were 19 instances indi-

cating that participants had forgotten to take their medi-

cines. These medicines were either taken later than required

or completely missed. Particular medicines were more likely

to be missed, such as statins, aspirin, metoclopramide, pan-

toprazole and vitamins, which were not seen as essential to

immediate well-being:

Whole life taking pills so it’s a routine. Sometimes I have forgotten

lipids [statins] at night. (Code 43, contact 2)

Five participants admitted to forgetting their insulin and

taking it later than prescribed. Forgetting to take medicines

was related to forgetting other activities of daily living,

such as forgetting to eat (Code 81) and forgetting to turn

off the oven (Code 34).

Actively resisting medicines. Eight participants disclosed

not taking their medicines because they deliberately chose

not to or were testing to see what would happen if they did

not. One participant did not take his medicines prior to see-

ing the doctor to see how he was without these medicines.

This participant was not adherent to his prescribed antihy-

pertensive medicines for many years, and when the doctor

cancelled the prescription, the person was left feeling that

he did not need them all along. A participant stated:

I’ve been taking medicines for so long I get a bit bored with it…

that’s just the way I am – for a week or so I may not take them

for a day. Occasionally I don’t take my medicines – 9/10ths of the

time I do – I like a bit of a break from them. (Code 65, contact 2)

Even participants who actively managed their illnesses

did not take their medicines all the time. A participant who

claimed to take his medicines as prescribed each day stated:

It [the medicine] does and it doesn’t [work] – my blood pressure is

up and down. The interviewer said, “Your blood pressure was high

there.” I didn’t take a pill that day. (Code 42, contact 5)

Wary of changes to medicines. Participants were wary of

changes in prescriptions which were frequent and were met

with trepidation:

They changed my meds [medicines] last week – changed my diabe-

tes med and increased dose. Diarrhoea and upset stomach. Stop

them for awhile and see how I go. (Code 25, contact 2)

Twelve participants had changes to their antihypertensive

medicines (most commonly, increased doses) during the

course of motivational interviewing. A different diuretic

may have been required because of high serum potassium.

A change in medicine brands, medicines running out at

different times and updates to insulin equipment inter-

fered with routine necessary to adhere to treatment as

prescribed.

Uninformed about health matters. Most participants

were generally uninformed about many important aspects

relating to their health, which was a barrier to taking

positive health action, for example what medicines were

prescribed for and the difference between brand and generic

medicine names.

Questioning the benefit of medicines. Nearly all partici-

pants questioned the benefit of their medicines when tests

fluctuated, and nothing else had changed in their daily

lives:

It [blood pressure] is either extremely high – 170/90 or 120/70 –

no pattern, absolutely. (Code 83, contact 4)

These fluctuations made participants dubious about under-

taking any new health initiatives, which was exacerbated by

the volume of prescribed medicines. Alternatively, partici-

pants became scared that they had run out of options to man-

age their health:

When you buy the stuff that doesn’t work, I think the worst.

(Code 25, contact 3)

Targets unrealistic. Taking medicines to reach set targets,

which were hard to achieve and seen as unrealistic, contrib-

uted to feelings of helplessness and being different to every-

one else:

A sugar of 7 [mmol/L] is hard to get – 8 is good for me. My

muscles ache from statins – will switch the meds [medicines]. Have

an appointment in a few weeks and will discuss side effect of

statins – haven’t stopped taking it yet. Plus iron levels. If something

is going to go wrong, it will with me. Everything goes wrong

with me and I don’t fit the standard norm. I am a difficult case.

(Code 39, contact 1)

Likelihood of taking action

Having a supply of medicines. Likelihood of taking action

was related to having a constant supply of prescribed

medicines:

Yeah, I’m alright. I’ve got plenty of pills. (Code 73, contact 4)

Support from family. Having someone to help participants

in taking their medicines was important for adherence:

As you know they [my medicines] are laid out for me – left to my

own devices, I don’t know how confident I’d be. I fob it off – my

wife puts them out. (Code 89, contact 2)

© 2013 John Wiley & Sons Ltd

8 Journal of Clinical Nursing

A Williams and E Manias

Medicine reminders and routine. Instigation of personal

reminder systems such as automatic mobile phone

reminders (Code 42), dosette boxes (Codes 21, 52, 81)

and routines (Codes 3, 34, 43, 83) was necessary for the

confidence and motivation to take medicines as pre-

scribed.

Discussion

Motivational interviewing calls uncovered a better under-

standing of the motivation and confidence of people with

coexisting diabetes, CKD and hypertension in taking their

prescribed medicines daily. Clearly, the goal of obtaining

optimum medication adherence to produce therapeutic

medication levels (Lee et al. 2006) was a major challenge

for this group. Participants manipulated their medicines

because they believed that they knew their bodies best, and

they had the opportunity and choice to make these manipu-

lations.

The findings highlight important psychoemotional issues

at play in the self-management of chronic disease (Furler

et al. 2008): the quest for personal control of health,

fear of the future and the role of stress and gender in

disease management. Personalised approaches to enhanc-

ing and supporting motivation and self-efficacy are likely

to have more success than purely focusing on unrealistic

targets in chronic disease self-management (Walker et al.

2011).

Participants’ motivation and confidence in taking medi-

cines was thwarted by complex medicine regimens. Fluctua-

tions in health and symptomless diseases, irrespective of

their seriousness, provided minimal incentives to take medi-

cines as prescribed. Tensions arising from trying to be

normal added further complexity to these participants’ lives

where priorities were forced for some sense of quality of

life.

Most participants demonstrated poor memory and

heath literacy, affecting self-management skills. Partici-

pants were overwhelmed even though they valued the

medicines that kept them alive. Ironically, the medicines

that sustained life, for example hypoglycaemic agents,

were a constant reminder of vulnerable health predica-

ments. Serious and vulnerable health states led partici-

pants to adopt various coping strategies, such as denial

and looking to blame (Williams et al. 2009), which were

sometimes counterproductive.

Most participants wanted control over their well-being,

but their actions were sometimes misguided due to dis-

trust of the healthcare system from previous negative

experiences. Additionally, partnerships with healthcare

providers were made more difficult by multiple providers.

Yet, once participants discovered they could control

aspects of their health, positive feedback reinforced desir-

able behaviour.

The modified HBM was a useful framework to under-

stand cognitive factors that influenced motivation and confi-

dence to take medicines as prescribed, although the many

subthemes tended to fragment analysis. However, the model

highlighted perceived barriers to act – multiple prescribed

medicines, no matter how well intentioned, set people up

for nonadherence. Actions to address the overarching domi-

nance of polypharmacy in chronic disease management are

warranted.

The main limitations of this study relate to data collec-

tion. Audio-taping the motivational interviewing calls

would have captured the nurse interviewer’s dialogue to

demonstrate how motivational interviewing helped to

promote motivation and confidence in taking medicines as

prescribed. People were recruited from only one metropoli-

tan hospital, and people’s experiences in other environ-

ments, such as rural and regional hospitals, were not

captured.

Conclusion

Disease self-management is a constant vocation which has

major psychosocial implications. Participants in this study

faced a constant struggle of affording doctors’ visits and

medicines, collecting medicines, taking medicines, trying to

understand the intricacies of treatments and being normal.

Further research into nurses’ use of motivational interview-

ing in people with earlier disease states may assist in uncov-

ering cognitive factors that enable and reinforce desirable

behaviour for a lifetime. However, in the absence of a cure,

diseases progress and people will become sicker and in need

of supportive interventions to help them manage their

chronic conditions.

Relevance to clinical practice

Reducing the complexity of medicine regimens in coexis-

ting diseases is paramount. Regular follow-up and feed-

back by nurses and the health professional team are

necessary to ensure patients have sufficient knowledge

and understanding to self-manage. Motivational interview-

ing is increasingly being used by nurses as an evidence-

based approach to enhance behavioural change. Nurses

who have most contact with the patient are well placed

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing 9

Original article Motivation and confidence in multiple medicine use

to use this counselling method in their daily practice. In-

dividualised psychosocial approaches that address the

emotional needs of patients delivered in naturalistic set-

tings by nurses are likely to have more success than

didactic, educational chronic disease self-management pro-

grammes.

Acknowledgement

We are indebted to the participants who freely gave their

time to participate in this research. This work was supported

by an Australian Research Council Linkage Postdoctoral Fel-

lowship grant (LP0774989).

Contributions

Study design: AW, EM; data collection and analysis: AW,

EM and manuscript preparation: AW, EM.

Conflict of interest

None.

References

Bakris G (2004) The importance of blood

pressure control in the patient with

diabetes. American Journal of Medi-

cine 116(Suppl 5A), 30S–38S.

Becker M (1976) Socio-behavioral deter-

minants of compliance. In Compli-

ance with Therapeutic Regimens.

(Sackett D & Haynes R eds). John

Hopkins University Press, Baltimore,

MD, pp. 40–50.

Dilorio C, Resnicow K, McDonnell M,

Soet J, McCarty F & Yeager K (2003)

Using motivational interviewing to

promote adherence to antiretroviral

medications: a pilot study. Journal of

the Association of Nurses in AIDS

Care 14, 52–62.

Furler J, Walker C, Blackberry I, Dunning

T, Sulaiman N, Dunbar J, Best J &

Young D (2008) The emotional context

of self-management in chronic illness: a

qualitative study of the role of health

professional support in the self-

management of type 2 diabetes.

BioMed Council Health Services

Research 8, 1–9.

Glanz K, Rimer B & Lewis F (2002)

Health Behavior and Health Educa-

tion: Theory, Research and Practice.

Wiley, San Francisco, CA.

Haynes R, Ackloo E, Sahota N & McDon-

ald H (2008) Interventions for enhanc-

ing medication adherence. Cochrane

Database of Systematic Reviews, Issue

2, Art. No.: CD000011.

Khunti K, Gray L, Skinner T, Carey M,

Realf K, Dallasso H, Fisher H, Camp-

bell M, Heller S & Davies M (2012)

Effectiveness of a diabetes education

and self management programme

(DESMOND) for people with newly

diagnosed type 2 diabetes mellitus:

three year follow-up of a cluster

randomised controlled trial in primary

care. British Medical Journal 344,

e2333.

Lee J, Grace K & Taylor A (2006) Effect of

a pharmacy care program on medica-

tion adherence and persistence, blood

pressure, and low-density lipoprotein

cholesterol: a randomized controlled

trial. Journal of the American Medical

Association 296, 2563–2571.

Miller W & Rollnick S (2002) Motiva-

tional Interviewing: Preparing People

for Change. Guilford Press, New

York, NY.

National Health and Medical Research

Council (2007) National Statement on

Ethical Conduct in Human Research.

National Medical Health and Medical

Research Council, Canberra, ACT.

Newman S, Steed L & Mulligan K (2004)

Self-management interventions for

chronic illness. The Lancet 364, 1523–

1537.

Ritchie J & Spencer L (1994) Qualitative

data analysis for applied policy

research. In Analyzing Qualitative

Data (Burgess RG & Bryman A eds).

Routledge, London, pp. 173–194.

Rosenstock I (1974) Historical origins of

the health belief model. Health Educa-

tion Monographs 2, 354–386.

Rueda S, Park-Wyllie L, Bayoumi A, Tynan

A-M, Antoniou T, Rourke S & Glazier

R (2009) Patient support and education

for promoting adherence to highly

active antiretroviral therapy for HIV/

AIDS. Cochrane Database of System-

atic Reviews, Issue 3, Art. No.:

CD001442.

Sowers J, Epstein M & Frohlich E (2001)

Diabetes, hypertension and cardiovas-

cular disease: an update. Hypertension

37, 1053–1059.

Swerrisen H, Belfrage J, Weeks A, Jordan

L, Walker C, Furler J, McAvoy B,

Carter M & Peterson C (2006) A

randomised control trial of a self-man-

agement program for people with a

chronic illness from Vietnamese, Chi-

nese, Italian and Greek backgrounds.

Patient Education & Counselling 64,

360–368.

Tong B & Stevenson C (2007) Comorbidi-

ty of Cardiovascular Disease, Diabetes

and Chronic Kidney Disease in Aus-

tralia. Australian Institute of Health

& Welfare, Canberra, ACT.

Vale M, Jelinek M, Dart A, Grigg L, Hare

D, Ho B, Newman R & McNeil J

(2003) Coaching patients On Achiev-

ing Cardiovascular Health (COACH):

a multicenter randomized trial in

patients with coronary heart disease.

Archives of Internal Medicine 163,

2775–2783.

Walker C, Furler J, Blackberry J, Dunbar

J, Young D & Best J (2011) The deliv-

ery of a telephone coaching pro-

gramme to people with type 2

diabetes by practice nurses in Victoria,

Australia: a qualitative evaluation.

Journal of Nursing & Healthcare of

Chronic Illness 3, 419–426.

Williams A, Manias E & Walker R (2009)

The role of irrational thought in medi-

cine adherence: a qualitative study of

consumers with diabetic kidney dis-

ease. Journal of Advanced Nursing 65,

2108–2117.

Williams A, Manias E & Walker R (2010)

The devil is in the detail: blood pres-

sure reduction in co-existing diabetes

and kidney disease: a single blind,

© 2013 John Wiley & Sons Ltd

10 Journal of Clinical Nursing

A Williams and E Manias

randomized controlled trial of a

consumer-centred intervention to

improve medication adherence. BioMed

Council Family Practice 11, 1–9.

Williams A, Manias E, Walker R & Gore-

lik A (2012) A multi-factorial inter-

vention to improve blood pressure

control in co-existing diabetes and

kidney disease: a pilot randomized

controlled trial. Journal of Advanced

Nursing 68, 2515–2525.

Winterstein A, Sauer B, Hepler C & Poole

C (2003) Preventable drug-related

hospital admissions. Annals of

Pharmacotherapy 36, 1238–1248.

Yang Y, Thumula V, Pace P, Banahan B,

Wilkin N & Lobb W (2009) Predic-

tors of medication nonadherence

among patients with diabetes in Medi-

care part D programs: a retrospective

cohort study. Clinical Therapeutics

31, 2178–2188.

Young D, Furler J, Vale M, Walker C,

Segal L, Dunning P, Best J, Blackberry

I, Audehm R, Sulaiman N, Dunbar J

& Chondros P (2007) Patient Engage-

ment and Coaching for Health: the

PEACH study – a cluster randomised

controlled trial using the telephone to

coach people with type 2 diabetes to

engage with their GPs to improve dia-

betes care: a study protocol. BioMed

Council Family Practice 8, 1–9.

The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of

clinically related scholarship which supports the practice and discipline of nursing.

For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http://

wileyonlinelibrary.com/journal/jocn

Reasons to submit your paper to JCN:High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1�316 – ranked 21/101

(Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reports� (Thomson Reuters, 2012).

One of the most read nursing journals in the world: over 1�9 million full text accesses in 2011 and accessible in over

8000 libraries worldwide (including over 3500 in developing countries with free or low cost access).

Early View: fully citable online publication ahead of inclusion in an issue.

Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur.

Positive publishing experience: rapid double-blind peer review with constructive feedback.

Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley

Online Library, as well as the option to deposit the article in your preferred archive.

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing 11

Original article Motivation and confidence in multiple medicine use