Perceptions of conflicting information about long-term medications: a qualitative in-depth interview study of patients with chronic diseases in the Swiss ambulatory care system

Abstract

Objective

Patients with multiple long-term conditions visit various healthcare professionals and are exposed to medication information from various sources causing an increased risk of patients perceiving contradictory medication information. The aims of this study are to: (1) characterise conflicting medication information perceived by patients with long-term conditions, (2) better understand the related impact on patients’ medication self-management and healthcare system navigation and (3) explore ways in which such events could be prevented.

Design

This study was conducted through qualitative semistructured interviews. Data were analysed using thematic analysis.

Setting

Community pharmacies and medical centres in Geneva, Switzerland.

Participants

This study included outpatients from April 2019 to February 2020. Patients were included after participating in a quantitative survey of perceived conflicting information about medications for long-term diseases.

Methods

Semistructured audiotaped interviews of 20 to 60 min following a pre-established interview guide to explore participants’ perceptions of conflicting information. Interviews were transcribed verbatim, and a thematic analysis was conducted with inductive and deductive coding using MAXQDA (2018, Release 18.2.3).

Results

Twenty-two patients were interviewed, until data saturation, mentioning indication or need for a medication as the main topic of conflicting information between two healthcare professionals. Perceived conflicting information often resulted from insufficient information provided and poor communication leading to confusion, doubts and medication non-adherence. Patients expected more information and more interprofessional communication on their medications. As a result of conflicting information, most participants learnt or were learning to take an active role and become partners of the healthcare providers.

Conclusion

The need to strengthen and improve communication and interprofessional collaborative practice among healthcare professionals and with the patient is emerging to increase the quality and consistency of information about medications, and consequently, to ensure better use and experience of medications.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study complements a quantitative questionnaire on perceived conflicting information about long-term medications.

• The semistructured interview guide allows for an in-depth exploration and understanding of the causes and consequences associated with conflicting information perceived by patients.

• Participants in this study differed in age and often took more than three medications, providing a variety of experiences concerning medication-related information.

• Beyond the definition provided to the term ‘conflicting information’ at interview start, participants perceived insufficient or missing information as conflicting.

Introduction

The number of sources of medication information has greatly increased over the past decades as have patients’ needs for information.¹ Although physicians have been ranked as patients’ preferred sources of medication information, patients often consult other sources such as pharmacists, nurses, medication package inserts or lay sources such as friends or family, television, social media or the internet.^2–4 Moreover, transitions from acute to long-term diseases related to an ageing population worldwide contribute to important changes in patients’ needs such as increasing visits to various healthcare professionals.^{5 6} A lack of interprofessional collaboration between different healthcare professionals increases the risk of providing conflicting information on patients’ disease or treatment management.^{7 8}

Although there is no international definition of conflicting health-related information, Carpenter et al have defined it as ‘two or more health related information that are inconsistent with one another’.⁹ Conflicting information provided by healthcare professionals has been associated with a lack of coordination and a lack of agreement on the information provision.^{10 11} Additionally, patient’s own beliefs and experiences with medication information may also contribute to perceiving conflicting information and leading to uncertainty regarding patients’ medication.¹² Perceived conflicting medication information can also be triggered by patients’ interpretations or poor communication with healthcare providers, causing barriers to proper understand health condition or medication.^{8 13} Perceptions of conflicting information expose patients to a poorer quality of care, decrease their trust in the healthcare system, increase medication non-adherence, and lead to a lack of clinical follow-up, medication efficacy and resulting in increased medication costs.^14–17

While some previously published studies on conflicting information focused on certain types of long-term diseases such as cardiovascular conditions^{18 19} or arthritis,^{20 21} others evaluated conflicting information perceived by pregnant women.^{22 23} Patients’ perception of conflicting information on long-term medications in European ambulatory healthcare systems remains still scarcely studied. Our quantitative study showed that 47% of patients diagnosed with a long-term condition in Switzerland reported perceiving conflicting information regarding one or more aspects of their medication such as indication, duration of treatment or even side effects.²⁴ As part of the same mixed-method research, this qualitative study aims to: (1) characterise the perceived conflicting information, (2) understand its impact on patient medication self-management and navigation in the healthcare system and (3) explore ways in which such events could be prevented in the future.

Methods

Design

This qualitative study was conducted from April 2019 to March 2020 through semistructured individual interviews. A thematic analysis was used to identify themes related to participants’ experiences and perspectives.²⁵ This study was conducted in parallel to a quantitative survey to investigate patients’ perceptions of conflicting medication information.²⁶ The Standards for Reporting Qualitative Research²⁷ were used in reporting the study.

Researcher characteristics

In-depth interviews were conducted by BS (PhD student and community pharmacist, trained in qualitative research) and MPS (head of the research unit and community pharmacist, experienced in qualitative research), who are two female researchers, unknown to participants and who introduced themselves as ‘researchers’ rather than clinicians to avoid the risk of influencing participants’ answers. Both BS and MPS were also involved in the quantitative part of the study. At the time of the interview, researchers knew that participants had reported perceiving conflicting information but did not access participants’ answers of the survey.

Setting and sampling strategy

Participants were recruited at three types of ambulatory care locations in the canton of Geneva (500 000 inhabitants), Switzerland: (1) an academic community pharmacy located at the exit of Geneva University Hospitals; (2) three partner community pharmacies located in different urban areas of the city and (3) one medical centre. A purposive sampling methodology was applied aiming to include a diversity of participants regarding age, gender, types and number of long-term diseases in a maximum of 30–40 participants or less if, thematic saturation was reached.²⁸ Thematic saturation was considered achieved when no new theme emerged from three consecutive interviews.²⁹ Participants were included after completing a quantitative survey regarding perceptions of conflicting medication information.²⁶ Inclusion criteria for the quanti-quali surveys were: (1) taking at least one medication for at least 6 months; (2) visiting at least two prescribers in the past 3 months; (3) being able to communicate in French, English, Portuguese or Spanish (in which BS was able to communicate). There was an extra inclusion criterion for the qualitative survey: (4) describing at least one experience with conflicting information regarding their medication in the past 12 months on the quantitative survey.

Data collection

The interviews were conducted in a private office at the University of Geneva, Switzerland or in a confidential counselling room in the community pharmacies according to the patient’s preference. Participation in the interview was compensated by 20 CHF to cover transportation costs. The face-to-face interview was 20 to 60 min long and used a predeveloped interview guide based on the literature review performed at the beginning of the study and after discussion with an expert committee (available as online supplemental data). The interview guide includes seven sections: (1) patients’ knowledge and understanding of their medication, (2) description of perceived conflicting information, (3) sources of conflicting information (professional and lay sources), (4) consequences of conflicting information, (5) resolution of conflicting information, (6) future improvements and retrospection on preventing conflicting information and (7) impact on trust in healthcare providers and in the healthcare system. Between sections 3 and 4, the 3-item Schooling Opinion Support mnemonic tool on health literacy was completed by the participants.²⁶

Data analysis

All interviews were audiorecorded and transcribed verbatim using Microsoft Office Word software (MSo and MF) and were labelled as ‘EQ-#’ for deidentification. Coding was performed using MAXQDA 2018, Release 18.2.3 . A thematic analysis following the six phases described by Braun and Clarke^{25 30} was undertaken to analyse our data. Researchers BS and MPS first familiarised with the data by reading transcripts¹ and proceeded to independently generating codes through a line-by-line semantic analysis.² Both researchers generated themes from the codes related to the research question³ and met to discuss and review themes to ensure homogeneity.⁴ If coders did not reach a consensus or in case of discrepancies, a third researcher independently analysed the interview to ensure scientific coherence and reproducibility until a consensus was reached. Themes were finally named⁵ and added to the written report.⁶ To ensure robustness of the data, two more researchers (KSB) and (EVG) read the scripts and participated in the revisions of the themes developed. Both deductive and inductive approaches were used since some codes were predetermined from the quantitative results.

Consent form and ethical approval

All eligible and interested participants signed a consent form clarifying that the collected data were coded and neither their physician, nor their pharmacist or nurse would have access to the individual answers provided. The ethics committee (Geneva ethics committee on research involving humans) approved the protocol in January 2019 (Protocol Nr 2018-01940).

Patient and public involvement

An expert patient was involved at several stages of this study including the design of the protocol and conduct of the study. Preliminary results were presented on a regular basis and feedback was obtained from the expert patient throughout the entire study.

Results

Participant characteristics

Among the 190 participants who stated having perceived conflicting information during the survey, 22 took part in the interviews. From interview 20 onwards, no new theme emerged from the analysis of the interviews and therefore no new participant was recruited after 22. All interviews were conducted in French with a mean length of 44 min (range: 13–73 min). Fifteen (68%) participants were female and 12 (54%) were 60 years old or younger. Seventeen (77%) participants rated their reading skills as very good or excellent, 11 (50%) participants stated having never needed anyone to help with reading information provided by a healthcare professional, and 5 (23%) participants reported needing such a support ‘sometimes’ or ‘often’. As shown in figure 1, the main medications prescribed to participants at the time of the study were for nervous system (29%), alimentary track and metabolism such as diabetes (24%) and cardiovascular system (13%). Three main themes emerged during analysis and are presented in figure 2.

Figure 1.

Medications being taken by participants (ATC/DDD classification).

Figure 2.

Three main themes identified regarding conflicting information through the analysis of the 22 interviews.

Characterising conflicting information

Origin of lack of agreement regarding medications

For most participants, conflicting information was perceived between two different healthcare professional sources such as general physicians and medical specialists, or physicians and pharmacists without involving lay sources or social media.

In fact it was supposed to be one dose [of ivermectin], and then the doctor, he made a mistake, so the pharmacy, they didn’t agree and then he [general physician] didn’t agree (…). (EQ5)

The main topics for which conflicting information was reported was the indication of the medication and whether the prescription was appropriate. Although participants reported this conflicting information as related to their medication, these often originated from a diagnosis discrepancy resulting in discordances regarding the appropriateness of a medication.

My general practitioner (…) told me that I have a huge B₁₂ deficiency (…) So she gave me two injections right away (…) and then a few days later, I had an appointment with the surgeon and his intern started screaming, saying “you don’t have to listen to your general physician, she doesn’t know anything, your B₁₂ is fine! So pff, [I was] completely lost”. (EQ2)

My doctor in Switzerland wants to eliminate the idea of gastric reflux, hence the idea of prescribing pantoprazole. And when I went to see another doctor in France, (…) he told me that he thought (…) I had rather a hypoacidity, which could also create this kind of thing. And that I should absolutely not take pantoprazole because I … so now I’m a bit between. (EQ7)

However, participants also described perceived conflicting information between information from healthcare professionals and their own perceptions and knowledge of medications in case new information provided by a professional differed from the patients’ treatment experiences and knowledge previously modelled with the help of other healthcare professional.

I had to go to the pharmacy to get some [acetylcysteine] [the person was used to take it on a regular basis] and I was told that it [acetylcysteine] is dangerous because I have high blood pressure. And that’s big news, because my blood pressure used to be ridiculously low (…) So I was a little worried about that. (EQ2)

Apart from the indication of medications, information on side effects sometimes contradicted patients’ experience of them. One participant described a conflicting information, which resulted from a confrontation between their own experience with the medication’s side effects and information provided by the physician, thus assuming that the physician deliberately denied the existence of a link between side effects and the medication with the intention to prevent non-adherence.

These are mainly contradictions about side effects (…) I have very serious gastric problems (…) I know that they are mainly caused by metformin (…) when I spoke to her [medical specialist] about these gastric problems, she told me that she didn’t see any link with the treatment (…) And so, my hypothesis is that she minimized them [gastric problems], so that I would be more adherent to the treatment. (EQ7)

Lack of information as a trigger for perceived conflicting information

Nearly all participants stated receiving insufficient information on their medications from their healthcare professionals. Such lack of information would be reported as conflicting once participants received or sought information from secondary sources such as relatives, medication package leaflets or another professional as illustrated below. This occurred especially when medications had more than one official indication.

Relatives: I didn’t think it was an antidepressant, she [specialist] had told me it [mirtazapine] was for sleeping, to put me to sleep and not to have bad ideas. (…) And it’s really by pure chance that my husband had had it for quite a long time, since we lost our daughter, he’s been on an antidepressant, and that’s why I stopped, I said “oh so this stuff, no I don’t want it, I don’t need it”. (EQ9)

Mediation leaflet: So I’ve had a lot of contradictions. I’ll start with the drugs I’m prescribed for neuropathic pain, so [clonazepam] and then [pregabalin] At first I was told that it was a drug only for neuropathic pain [pregabalin], which suited me because [clonazepam] wasn’t enough, (…) Then well, I must be weird but I read the package leaflets (laughs) (…) I learned that it was used as a tranquilizer. And that kind of medicine is a real problem for me, I don’t like it. (EQ4)

Other professional: I was prescribed clonazepam and was told that it calmed the pain, then when I met the pharmacist, I had a completely different version (…) It’s more of a sedative, something that helps you sleep. (EQ4)

Insufficient and thus conflicting information as a result of a lack of time spent with the healthcare professionals

For most participants, insufficient information was associated with a lack of time on the side of healthcare professionals, especially time spent on consultations, described as short, often interrupted, or leaving little space for patient’s questions and involvement. Associated with a lack of time, a perceived lack of listening, empathy and interest in their lives and experiences were reported.

And what was the major contradiction between what the lung specialist said and what the emergency doctor said that bothered you?—I’d rather say how they explained it [use of asthma inhalers] to me. I was there, I wasn’t feeling well, they explained it to me very quickly, and then they told me a few weeks later that it was totally wrong. (EQ3)

They [physicians] never have time, we can’t talk too long. (EQ18)

I have the impression that I am heard but not listened to (…). (EQ22)

Consequences of conflicting and insufficient information

Medication non-adherence

Perceived conflicting information decreased medication adherence in participants who described either (1) not taking the medication as prescribed but also (2) temporarily stopping it without consulting their healthcare professional.

Yeah, sometimes I hear one version, then another, then another, so I’m totally lost, so I’m like, what am I doing? Who do I follow? But in the end, well sometimes I don’t take them [medications]. (EQ3)

But between all these steps [of information from different sources], until I understood that a drug could have several uses (…) there was a period when I didn’t take it [pregabalin]. (EQ4)

As shown in the next verbatim, differing assessments of the medication between two physicians can prompt patients to adapt the treatment.

When I told him [general physician] the amount of this medication [venlafaxine, previously prescribed by a specialist] I was taking per day, he thought it was a lot. That’s why (…) I decided on my own to lower the quantity a bit. In other words, I used to have to take 75 mg in the morning and 150 in the evening, and now I take twice 75. (EQ10)

Although conflicting information did not always result in medication non-adherence, in some cases participants felt hesitant to take their treatment.

I take them [medications] reluctantly… (EQ4)

I didn’t do it [stop the medication]. But it’s true that I would have been tempted to do it. (EQ8)

Negative emotions, insecurity and doubts

Perceived conflicting information raised doubts in participants who reported not knowing which source to trust or believe.

So, I’m a bit in between. (EQ7).

I don’t know who to believe, because I am not a doctor (…). (EQ3).

In addition, some participants expressed disappointment at not being invited to participate in the decision-making process especially when they felt that they had received insufficient information leading to their perception of contradictory information.

I was a bit angry because I didn’t know (…) I was taking something that I didn’t actually know was an antidepressant. I would have understood if someone had told me! (EQ9)

Other than questioning healthcare professionals, some participants reflected on their own responsibility in generating conflicting information and questioned their ability, as patients, to understand the information that they received.

Well, I felt, well … a bit uncomfortable, and then a bit anxious because I said to myself, maybe I shouldn’t have asked both of them [physicians]. (EQ19)

I asked myself whether … whether it was me or them [physicians] (…), am I the only patient who causes so many problems [with understanding the information]? (EQ17)

Visiting other healthcare professionals and breaking therapeutic bonds

Interviews showed that perceived conflicting medication information led a few participants to visit a different physician to seek another opinion to resolve the conflicting information. In some cases, there was also a break in the therapeutic bond when patients stopped consulting with a certain healthcare professional.

Well, it was the umpteenth time that I had the impression that I wasn’t being given the information because there wasn’t time (…) As a result, it was the last time I went to see the doctor I’d known for almost 20 year [conflicting information regarding the choice of oral vs injection medication]. (EQ1)

For two participants, the conflict between different specialists regarding an appropriate diagnosis and treatment resulted in frustration regarding the medical care but also extra personal and global financial costs.

They [medical specialists] don’t agree with each other and then … for me, it’s just tinkering. (…) And then it costs so much money to go and see all of them [specialists]. They don’t realize it, they’re just cash drawers, they don’t care. (EQ5)

So, there I was, participating in this system that I don’t like. I would have liked to go to the doctor once and have it sorted out like that, without it costing anyone anything. If I add up all the doctors’ bills and all the creams, everything I’ve been given, well yeah, it’s way too expensive for what I’ve had, and that’s not the way to lower the cost of health insurance. (EQ21)

Patients’ expectations towards healthcare professionals

Patients need more information on their medications from healthcare professionals to take part in the decision making process

Most participants mentioned the need for more information regarding their prescribed medications, particularly information that would help them understand how their medication works, their beneficial effects as well as potential side effects.

What is this drug? I mean, what category, what type. What would be its action? What are its side effects? (EQ4)

One participant state needing a precise advice from the healthcare professionals which highlights the link between perceived clarity, congruency of information and the need for patients to have healthcare professionals professionally involved in providing information.

A clear and precise opinion, because otherwise we don’t know who to listen to, how to proceed. (EQ3)

The need to understand the rationale behind a prescription as to explore other options is mentioned by some participants who discuss their active participation in their care as a key aspect to prevent perceiving conflicting information.

I always ask: “Why are you giving me this [medication], why are we doing this, why aren’t we doing something else?” I’m used to it with my doctor, we just talk. I ask questions. (EQ22)

Patients as active partners

Through difficult experiences related to insufficient or conflicting information on medications, most of the participants learnt to assume a more active patient role by asking questions, seeking and transmitting information, and taking part in the decision-making process, whether invited or not. Some patients expressed themselves on the learning process for developing such skills. Even further, they got to learn that they were actors not only in preventing but also in resolving conflicting information.

I learned over time that now, as a patient, I also have to know how to ask questions, how to work together with the doctor. (EQ17)

And at some point it’s up to me, it’s almost up to me to go back to my doctor and say ‘but listen, they actually told me over there that it was the [metformin] that was giving me these problems’ … so I’m the one who has to do that job, I feel.—Passing information from one side to the other?—Yeah. (EQ7)

Increase interprofessional communication to provide more congruent information

To decrease the lack of communication among different healthcare professionals especially regarding complex cases with several medications, some participants suggested that the different healthcare professionals share more information and reach an agreement regarding the medication.

I would have liked that, with my whole panoply of doctors and medications, that they, even a videoconference or I don’t know, that they consult each other and agree on a treatment, but all among themselves. Yeah. Because in the end … they were aware of all this, of all this treatment, but … they didn’t consult each other. (EQ11)

I’d say “no, but come to an agreement, and tell me what to do”, rather than being sent back and forth (EQ8)

At some point they [medical specialist and general physician] have to talk to each other. And talk to me. (EQ2)

Discussion

Our previous quantitative study showed that 47% of included patients had perceived conflicting information related to one or more medication topics mainly from professional sources such as physicians and pharmacists leading to non-adherence to medication as well as changes in their navigation in the healthcare system.²⁴ Given the high prevalence of this phenomenon, the aim of this qualitative study was to explore participants’ experiences with perceived conflicting information and identify their causes and consequences. To our knowledge, this was the first study to describe patient perceptions of conflicting information related to their long-term medications in the Swiss ambulatory healthcare system.

Our study describes the indication or need for a medication as the main topic for perceived conflicting information between two healthcare professionals. This often resulted from uncertainty around the diagnostic process leading to discordances in the prescription. Our data show the importance to manage such uncertainty by better discussing it with patients as well as involving them in the process, which is confirmed by the literature.³¹ Our results also show that medical specialists, general physicians and pharmacists are the main reported sources for such perceived conflicting information which is consistent with results from the quantitative study.²⁴ Surprisingly, lay sources such as the internet, social media, friends and family were less often reported as sources for conflicting information, although they are frequent sources of information among patients.³²

Participants in this study reported insufficient information as a main source of perceived conflicting information and communication bias leading to confusion regarding their medication. This occurred when participants had a certain knowledge or experience with the medication but also when they sought or received information from other sources. This is especially important with medications presenting more than one official indication such as medications used for chronic pain.³³ Some participants reported that they would like more information on the mechanism of action of the medications and on the different therapeutic options available. This finding is consistent with reports from other studies revealing the need for general information on medications and safety issues and possible drug–drug interactions.1 17 34–38 Information regarding side effects was often reported as missing information, reinforcing the results of our quantitative survey, that little information is provided on side effects.²⁶ Discussing side effects is a delicate matter and while healthcare professionals willingly explain the benefits of medications, they often intentionally avoid discussing side effects—which are unlikely to occur—so as not to increase patients’ distress and treatment non-adherence.^39–41 Patients’ experience, knowledge and needs are key elements in shared decision-making although not always considered when information is given to patients.^42–45 In sum, consistent and accurate evidence-based information on medication provided by different healthcare professionals would help patients make informed decisions about their treatments.^{10 46}

According to our interviews with patients, insufficient information—perceived as conflicting—results from a lack of time and active listening on the part of healthcare professionals. Lack of time is a well-known factor that decreases the quality of the healthcare professional–patient relationship.^{47 48} Medical decisions, based on diagnostic and prescription processes, are complex and can evolve over time. In our study, participants did not perceive this evolution in decisions, with the risk of associating evolution with conflict if the changes were not clearly explained to them. When there is a lack of time, the patient might not find the opportunity to ask questions or process the information given, which can not only affect patients’ perceptions of the information received but also their trust in the healthcare professional.⁴⁹ In a partnership model, healthcare professionals and patients spend an equal amount of time talking, which can contribute to tailored interactions and greater patient satisfaction, at least making a better use of time available if it cannot be extended.⁵⁰

Our results described three frequent consequences of perceiving conflicting information. First, conflicting information caused patients to be non-adherent to their medication in one or more phases: initiation, implementation and discontinuation.18 20 51–53Second, it led some participants to visiting several healthcare professionals, which is known to increase health-related costs for both the patient and the system.⁵⁴ Thirdly, it caused uncertainty, insecurity, even anxiety regarding ones’ medication. Such negative affects resulted in some participants not feeling involved in the decision-making process. Patients’ adherence decisions to their medications are influenced by their personal beliefs about the need for a specific treatment balanced by concerns about its potential harms.^55–57 Patients’ self-efficacy is influenced, among other determinants, by received health information.⁵⁸ If there is a lack of agreement from different sources on the indication or suitability of a medication, the patient’s perceived needs can be unmet, potentially leading to medication non-adherence.^59–64

Interestingly, in accordance with literature, after exposure to conflicting information, many individuals tended to define their role in the healthcare system differently, to endorse a more active role and to participate in shared decision making with their prescriber.^{65 66} This change in behaviour is either something that the patient is willing to do or that they feel forced to do to find their way around the healthcare system.⁶⁷

Given recent developments in interprofessional practice and patient partnership, reinforced education of both patients and healthcare professionals may help prevent both conflicting and insufficient information and improve overall communication.^{19 68} Patients need to be informed and trained to endorse their new roles in terms of rights and responsibilities.^{68 69} Further development of pregraduate and postgraduate interprofessional education will improve communication in healthcare, shared leadership and a better understanding of each team member’s competencies and roles, including the patient.⁷⁰ A coordinated interprofessional network could alleviate this problem with the patient directed to healthcare professionals such as pharmacists and nurses for tailored and timely treatment information. Understanding team member’s roles is crucial to increase the efficacy, safety and cost-effectiveness of patients’ medications in an era where medications are more and more effective and targeted.^{70 71}

There are some limitations to this study. First, this study described the perceived conflicting information on medication which does not mean that the information provided by healthcare professionals was actually conflicting, but rather that it was perceived as so. Although this can be considered a limitation, the authors believe it to be a strength to focus on patient reported experiences with medications, which have gained attention recently. Second, we cannot exclude recall bias, since patients were asked about conflicting information perceived in the past 12 months. The recall period length depends on the objective of the study as well as the information we aim to collect. Therefore, we defined the recall period length to 12 months which not only allow for a greater information collection but also to be aligned with the period length in the quantitative study. Additionally, we cannot exclude that some patients may have recalled events that were older than 12 months. Thirdly, some difficulties were encountered when recruiting patients to participate in the interviews because of the time burden. Some patients also believed that their experience with perceived conflicting information did not have sufficient consequences and was therefore not worth discussing any further. However, to overcome this, flyers were posted in different clinical settings to expand the diversity of locations (eg, various community pharmacies, primary care facilities and through patient associations), participants could choose the location for the interview (pharmacy counselling room or university room) according to their preference and for some participants, interviews took place immediately after completing the quantitative survey. Fourthly, qualitative studies always reflect the data of patients willing to participate and selection bias cannot be ruled out. This selection bias was limited as much as possible in the recruitment process. In the first step (survey recruitment), the terms ‘conflicting’ or ‘contradiction’ were never mentioned, and the study was presented as investigating information provided to patients about their medications for long-term diseases. Then, the qualitative study was presented to all participants who stated they had received conflicting information. Lastly, three quarters of participants reported having a good or high health literacy. Patients with high literacy who often tend to seek more health-related information⁷² are probably the most at risk of perceiving conflicting information and therefore exposed to their consequences. This deserves attention in future research.

Conclusion

This in-depth evaluation of patients perceived conflicting information on medications highlights the complexity of communication with patients in the ambulatory healthcare system about the long-term medications they are prescribed. Subtle discrepancies of standpoints can have damaging consequences. Innovative interprofessional models of care with advanced and structured communication, and improved collaboration between healthcare professionals and patients in the community are essential to respond to the evolving medication information needs of the outpatient population. Research needs to keep investigating how patients with long-term conditions respond to conflicting information, how this information affects decision-making about medication management, medication adherence and care trajectories, and how to improve communication in healthcare in partnership with patients.

Data availability statement

Data are available upon reasonable request. The datasets generated and analysed during the current study are available from the corresponding author on reasonable request.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).

Ethics approval

The Geneva ethics committee on research involving humans approved the protocol in January 2019 (Protocol Nr 2018-01940). Participants gave informed consent to participate in the study before taking part.