Keywords

1 Introduction

For elderly people with chronic diseases, medication is one of the most widely accepted and adopted ways of treatment. Previous researches and reports showed that both physiological and psychological factors have influence on medication adherence. In physiological aspects, elderly patients are more likely to experience hearing loss, impaired vision, memory deterioration, cognitive decline, emotional instability, and other disorders, while in psychological aspects more on anxiety feeling, intense fear, and depression when they experience diseases. The complex and diverse experience of the elderly patients as well as their knowledge background, family status, financial situation, etc. make their behavior difficult to study and to change.

How to promote medication adherence for elderly is a global challenge. Non-adherence will ultimately increase the likelihood of treatment failure [1], and it may lead to disease complications, increase unnecessary medical expenses and expenditures, cause disability and even premature death too [2]. In all patient age groups, the elderly population earns the largest benefit from medication but they are also the most dangerous group when medicine adherence is not ensured [3].

In developed countries, about 50% patients are adherent to prescriptions [4, 5]. This figure is much lower in developing countries where healthcare resources are limited and healthcare services are relatively poor. In China, the general medication adherence is around 43% [2]. As the world’s most populated country with elderly people, China accounts for 1/5 of the global total elderly population [6]. In 2010 during the sixth National Census, a total of 17,658,702 elderly aged over 60 carried out a self-assessment of their health status. Unhealthy elderly accounted for 16.85% of that group [7].

With the increase of elderly population in China, medication adherence is becoming an important issue in healthcare industry. It is necessary to cope with this issue with some design solutions developed to support patient’s behaviors. Therefore, in the College of Design and Innovation (D&I) of Tongji University, researchers have conducted a study with the following goals:

  • To understand the current situation of medication adherence for elderly in China;

  • To summarize key findings in both cognitive and behavioral aspects;

  • To propose potential design solutions based on the key findings.

2 Research

2.1 Methods and Process

Questionnaire

The purpose of the questionnaire is to collect overall information of elderly patients’ medication adherence, to provide data for targeted selection of in-depth interviews and to support the follow-up interview design. The questionnaire for elderly patients is composed of four parts: medication adherence, disease and therapy, healthcare and physician-patient relations, and other relevant and basic information [8]. In the medication adherence part, a self-report questionnaire, the eight-item Morisky Medication Adherence Scale (MMAS-8) is applied [9]. All items are translated into Chinese. Collected data are presented in Fig. 1.

Fig. 1.
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Questions and results of the MMAS-8

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The questionnaire was mainly carried out through the network and paper. The network part was created by a network platform named ‘Wenjuanxing’ and then the links were forwarded to participants. The paper part was carried out directly to distribute questionnaire to participants. In total 60 elderly patients were recruited from Shanghai, Hangzhou, and Zhuji city in China. The following standards were considered in choosing the participants:

  • Over 45 years old, outpatient

  • At least one year medication-taking experience

  • At least once per day of medication-taking

  • At least with one chronic disease

  • Having hospital experience within 6 months

Interview

The purpose of interview is to verify the findings or speculations in the questionnaire results and to collect future expectations in the healthcare domain. The interview is conducted in a semi-structural way with both elderly patients and care providers. For elderly patients it is conducted with the same four parts as in the questionnaire, but more freely. For care providers it is planned to collect the following information:

  • Brief introduction of the job content and workload

  • The whole process of treating a patient

  • Experience of the elder patient with chronic disease

  • Experience of the medication adherence issue

  • Attitude and standpoint towards physician-patient relations

  • Expectation of the future healthcare domain

Five elderly questionnaire respondents are chosen to interview. Another five care providers are contacted for one-to-one interview (Table 1).

Table 1. Basic information of interviewees
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2.2 Result Analysis

Basic Situation

The questionnaire is conducted with 25 male patients and 35 female patients. Their mean age is 61 years old. Among them, 29 (48.3%) patients have more than three diseases, and all participants over 80 years old have at least three diseases. In general, the medication adherence level is low. From the data in Fig. 1, it can be seen that 46 (76.7%) are in low medication adherence category, 13 (21.6%) the medium category and only 1 (1.7%) the high category. Basic information in the ways of communication shows that mobile phones are popular among them, 29 (48.3%) use smart phone app and 25 (41.7%) use cellphone calls.

Cognitive Aspect

As Fig. 1 shows, 43 (71.7%) participants feel hassled about sticking to medicine treatment plan. It is very common that patients reduce or stop taking medicine without telling doctors. 25 (41.7%) participants have done it because of adverse drug effect; 41 (68.3%) stop medicine taking as they believe that the symptoms are under control. In respect of physician-patient relations, 38 (63.3%) participants consider that the physician-patient communication is a hierarchical relationship, while 17 (28.3%) consider it as partner or friend. And, the latter has better medication adherence than the former. According to the interview, most of the elderly are also eager to gather health relevant information rather than to take medication according to prescription.

Behavioral Aspect

According to Fig. 1, 38 (63.3%) participants respond that they forget to take medication sometimes. Most of them read drug instructions. As shown in Fig. 2, when using drug instructions, 52 out of 60 patients concern time and dose, 31 pay attention to side effects and expiry time. Regarding the ways of collecting health information, 39 participants collect it from doctors, beside the ways of TV-program, Internet, newspaper and magazine. According to the interview, some patients involve in prescription in some ways. But they don’t much involve in developing treatment plan of their doctors.

Fig. 2.
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Some results of the questionnaire

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Healthcare Aspect

As shown in Fig. 2, doctors are more likely to provide diets and medication information, than to give physical exercise and lifestyle advice. The information on psychological aspects is still less. Furthermore, different care providers with different functions have different understanding on medication adherence. There are no unified methods to follow to improve adherence. In fact, the patients are facing with information with contradictions in practice.

2.3 Key Findings

Key findings are summarized in the aspects of cognitive, behavioral and healthcare relevant, as following:

Cognitive Aspect

  • Neglect the importance of adherence

  • Lack medication relevant knowledge

  • Pay attention to health, but have a negative attitude towards medication

  • Good physician-patient relationship is beneficial to improve adherence

  • Lack understanding the situation of treatment

Behavioral Aspect

  • Often forget to take medicine

  • Most of them read drug instructions

  • Pay attention to the medication time, usage and dosage, followed by side effects

  • Methods of collecting health information are various

  • The elderly involve in medicine treatment decisions

Healthcare Aspect

  • Doctors’ advice is not comprehensive

  • Different care providers have different impact on medication adherence

3 Design Proposal

3.1 The Transtheoretical Model

The transtheoretical model (TTM) is a model of intentional behavior change which has applied to a wide range of health behaviors, including medication adherence [10]. It uses a temporal dimension, the stages of change, to integrate processes and principles of change from different theories of intervention. Six stages of change and ten processes of change have been identified as Fig. 3 [11].

Fig. 3.
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Introduction of the transtheoretical model

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3.2 Design Strategies Proposal

As shown in Table 2, the first two columns are stage of changes and process of changes from the TTM. The research finding column is corresponding insights which should be solved and which will guide the design strategy. The techniques of intervention column include techniques provided by the TTM in order to design measures. And data is referenced, which had an experiment to estimate overall mean effect sizes (ESs) for medication adherence of various interventions through meta-analysis [12]. ES0 and ES1 denote the value of ES before and after the intervention. The higher the ES value, the larger the impact of intervention behavior. Integrating the guidance of the TTM, research findings and referenced intervention characteristics, corresponding design strategies are presented at the sixth column of Table 2. A service system design is proposed according to design strategies.

Table 2. Proposing of design strategies
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3.3 Medication Management System Proposal

The design of medication management system pays attention to the process and experience of medication treatment. As a service solution, it includes designing the using process of the service platform, the interactive logic of an App, and the low fidelity interface and product design. Main functions of the system and implementation methods are presented by integrating design strategies in Table 2.

Various Accesses to Health Information

Health information is promoted and subscribed with the App. In order to improve the awareness, information is presented to emphasize the importance of medication adherence. Other functions such as popularizing the knowledge and disease, presenting positive and negative examples are also included. The patients can also consult the doctors directly via the App. A community communication platform is established for the elderly to share experience with each other.

Emphasis of the Time, Usage and Dosage in the Instructions

When buying the drugs, succinct written instructions with enlarged font are pasted onto pill bottles by staff to make it clear for the elderly. Design a drug packaging as a special container that indicates the time and dose. The same instructions are presented within the App to understand their medicine information.

Remind Taking Medicine

When it’s time to take medicine, the smart bracelet will remind taking medicine by sound and vibration like an alarm clock, which can be stopped by the patients before they take medicine. A second reminder will be initiated by the smart bracelet after short time to ensure medication taking.

Record and Monitor the Situation, and Provide Feedback

As the bracelet remind again, if having taken medicine, press the button again, the interface of smart phone will light up to record the medication in concern. Meanwhile, the smart bracelet can monitor pulse, movement and sleep. The App can then provide feedback and advice on health situation of the patients, which makes them understand their physical and treatment condition, assess their situation before and after medication, etc. Furthermore, if the elderly is monitored with a dangerous situation, the system will give immediate feedback to doctors for an emergency.

4 Design Solution

4.1 Design of the Service Usage Process

Figure 4 is the service blueprint showing the service process for the elderly with four stages: aware, join, use, and develop. The service evidence, stage, user behavior, front service, back service and backstage process are presented in column. The user behavior row presents a series of actions and interrelations between them. The front service and back service rows present service actions which are visible and not visible to users respectively. The backstage process row shows the support process of service. The service touch points mean service encounters for the elderly. The service evidences are listed on the top, indicating tangible evidence exposed through the whole experience process.

Fig. 4.
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The service blueprint

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The Aware Stage

The aware stage is a cultivating cognition stage. Various medication and health related information is available to the elderly, so that they can well accept the adherence knowledge then start to develop a habit based on their consciousness.

The Join Stage

The join stage is a guiding stage, in which user behaviors like buying drugs, taking medicine are well supported. Succinct written instructions add tips and reconstruct the medication environment when buying and taking medicine. Bracelet reminding provides stimulus and improves adherence from the behavioral aspect.

The Use Stage

During the use stage, the service becomes an assistant for the elderly. They can record medication situation and monitor pulse, movement and sleep. Moreover, the recorded data can give them health suggestions after integrating. Disease symptom self-monitoring enhances their confidence and understanding of themselves.

The Develop Stage

During the develop stage, the service becomes a friend of the elderly. It is possible for the elderly to share experience, evaluate impacts before and after medication, which provides them convenience and makes them more independent.

In short, the functions of the service are constantly changing, from cultivating cognition, to guiding, assisting, and becoming a friend of the elderly. Forming a habit is a long process, which means that the positioning of the service and the relationship between the users and the service are dynamic.

4.2 Design of the Service System

The service system is designed to operate in the way shown in the service map in Fig. 5. When the elderly buy drugs from pharmacies, they can get succinct instructions, which are provided by the service platform. The smart bracelet can provide reminding and monitoring service under the support of service platform. After calculating the recorded data, the service platform gives medicine and health related feedback to the elderly and the doctor. The elderly can know themselves better, and the doctor can adjust prescriptions according to the feedback.

Fig. 5.
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The service system map

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4.3 Design of the App Interactive Logic

The logic map shows the framework of App in Fig. 6. There are four tabs in total, namely Homepage, Record, Consultation and Mine. The Homepage displays the current time as a clock and subscribed health and medication information. In the Record tab, the elderly can understand their medication, pulse, movement and sleep situation. The elderly can consult doctors and pharmacists directly via the Consultation page, as well as share feelings in the community. As for the Mine tab, the elderly are able to check their medicine list, read the feedback and set their personal information. The low fidelity interface design is shown in Fig. 7.

Fig. 6.
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The logic map

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Fig. 7.
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The low fidelity interface design

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4.4 Design of Ancillary Products

The instruction design is shown in Fig. 8. The left side contains time, dosage and side effects, making it clear for the elderly. The right side contains the medicine name and a QR code. The instructions are provided by the service platform and posted onto the medicine package by the staff in pharmacies. When the elderly buying drugs, the QR code is scanned by the staff and information of patients and drugs are recorded correspondingly into the service platform. Then the elderly can check their medicine lists with App.

Fig. 8.
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Instruction on packaging

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The smart bracelet design is shown as Fig. 9. With a small screen on the bracelet, it shows the current time. When it’s time for medicine, it reminds the elderly taking medicine through sound and vibration. Then a button can be pressed to indicate the confirmation and to stop the reminding. Sensors within the smart bracelet monitor the pulse, movement and sleep. The recorded information will be sent to the service platform and integrated into health feedback to the elderly and the doctor.

Fig. 9.
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Smart bracelet

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5 Discussion

In China, aging and the healthcare for elderly are induce issues which should be well considered. This paper presents a study on investigating the current situation of medication adherence for the elderly in China. Key findings are concluded as follows: in cognitive aspects, the consciousness on medication is not strong; in behavioral aspects, forgetting is the most common situation.

Proposal of design strategies is made by integrating the transtheoretical model, the study findings and referenced experiment data. The way of techniques of intervention are chosen based on the design strategies, which provides good way for propose a final design solution, hereby in form of a service system design. There might be other effective design strategies. The way to select design strategies should be further studied. The value and feasibility of different design strategies should be evaluated with a set of criteria. The priority of design strategies should also be well studied to connect it to the results of the investigation on current adherence situations in China.

With the change of cognition and behavior of the elderly, the relation between users and service is changing; therefore, the service experience is dynamic and holistic. It is necessary to evaluate and improve the design constantly when needed. In addition, improving the medication adherence is a change of group behavior, which involves diverse factors in social development. Multifarious effort is required for improving adherence, including hospital medication regulations, service provision through a platform, and cooperation among hospitals, pharmacies, community, and the users, etc.

As many elderly use smart phone as a communication way, the service provision could be well implemented based on an App with necessary functions to promote adherence such as provide medication and healthcare knowledge, emphasize importance of adherence to increase consciousness, assist patient well manage medication information and medicine taking process, monitor health status to feedback the effect of medication, etc. Ancillary products such as instruction label with written information and QR code, smart bracelet, etc. can be designed to connect the elderly well with the service platform.

There are several limitations to the study. Only elderly patients from three cities in the Yangtze River Delta, which is a developed region in China, are investigated. The impact of urban differences has not been considered. The influencing factors such as level of income, social classes and living style, etc. are not included in the study. These factors will be considered in the future studies.