Evaluation of acceptability and feasibility of using manual pill organizers and pill reminder apps for improving medication adherence among elderly population from rural Maharashtra

Abstract

BACKGROUND:

Approximately 40%–75% of elderly individuals suffering from chronic diseases are nonadherent to medications. Manual pill organizers (MPO) and pill reminder apps (PRAs) are simple interventions that can improve medication adherence. This was a mixed-methods study to understand the feasibility and acceptability of MPO and a locally developed PRA amongst elderly individuals from rural Maharashtra.

MATERIALS AND METHODS:

Sixty elderly individuals aged 60–80 years taking three or more oral medications with access to a smartphone were randomized to receive MPO, PRA, or MPO + PRA for 3 months (n = 30). The outcome measures included acceptability and feasibility using qualitative methods, and usability was measured using a system usability scale.

RESULTS:

Both MPO and PRA demonstrated good system usability and ease of independent use. The findings of the qualitative study highlighted reduced dependency on caregivers, reduced chance of missing a pill, and ease of carrying medicines during travel as benefits of MPO. User-friendliness, ability to take medication on time, and caregivers’ satisfaction were reported benefits with PRA. Reported challenges included initial hesitancy, the additional workload of filling the MPO, alarm malfunctions, and dependency on family members for using PRA. Medication nonadherence due to forgetfulness significantly improved from 52% to 65% at baseline to 90%–100% at the end as reported using Medication Adherence Rating System-5. Participants in the combined group did not report any difficulty using the two interventions together.

CONCLUSION:

The study demonstrates good feasibility and acceptability of MPOs and indigenously developed PRA either alone or in combination among the Indian rural elderly population. CTRI registration: CTRI/2024/01/061975 (Registered on- January 29, 2024).

Introduction

The World Health Organization has defined adherence as “the extent to which a person’s behavior (taking medication, following a diet, and executing lifestyle changes) corresponds with agreed recommendations from a health care provider.”[1] Nonadherence to medications refers to deviations from prescribed treatment and includes underuse, overuse, or incorrect use of medications. It can be categorized into two main types: unintentional nonadherence, which may result from factors like forgetfulness, lack of understanding, physical difficulties, or the complexity of the regimen; and intentional nonadherence, where an individual consciously chooses not to follow the treatment as directed.[2]

Medication nonadherence has been reported in around 50% of individuals on the long-term treatment for the management of chronic diseases and the problem is likely to be more severe in developing countries, where access to healthcare is limited.[1] Medication nonadherence poses a significant risk in elderly individuals leading to inadequate disease management.[3] Approximately 40%–75% of elderly individuals suffering from chronic diseases are nonadherent to treatment.[4] Poor medication adherence can lead to disease progression, development of comorbidities, reduced functional abilities and quality of life, excess healthcare costs, increased use of medical resources, and prolonged hospital stay.[5]

Medication-related factors, including dosing regimen, side effects, polypharmacy, and patient-related factors such as cognitive function, health literacy, and multimorbidity, pose significant barriers to medication adherence in elderly individuals.[6,7]

Several adaptable technological solutions exist to improve medication adherence, such as pill organizers, reminder apps, electronic pill bottles, and electronic medication management systems.[8] However, many of these interventions are not affordable to the general Indian population and may be complex to use, especially among elderly individuals. A manual pill organizer (MPO) is a simple and easily available device that has been shown to improve medication adherence among elderly individuals in a few studies. Click or tap here to enter text.[9,10] However, there is no evidence of the impact of MPO in improving medication adherence among the Indian elderly population.[10]

Pill reminder apps (PRAs) are inexpensive, scalable, and accessible to individuals with smartphones. They do not require separate devices or packaging which allows them to be easily implemented.[11] However, most of these apps are not tailored to the Indian context, lack support for regional Indian languages, and are difficult for elderly users to navigate. There is limited conclusive evidence on the feasibility of these interventions in the Indian elderly population and their impact on medication adherence, health outcomes, and health economics. Well-designed randomized controlled trials (RCTs) are needed to investigate if these simple interventions can improve medication adherence in developing countries.[12] The paper describes a pilot study on the feasibility and acceptability of using MPO and a locally developed PRA in elderly individuals from rural Maharashtra on multiple medications. The findings from this phase will inform the next phase – a multicentric randomized controlled study which will evaluate the effectiveness of these interventions in improving medication adherence, health, and health economic outcomes.

Materials and Methods

Study setting

The study was conducted at the Vadu Rural Health Program, a community-based department of KEM Hospital Research Center, Pune, located 35 km from Pune city. The department has access to around 200,000 rural populations from the Shirur and Khed blocks of the Pune district through the Health and Demographic Surveillance System covering 22 villages. About 7% of the population is above 60 years of age with a literacy rate of 90% and smartphone access at approximately 88%.

Design

This study was a mixed-method, randomized, single-center study conducted from Jan 2024 to Jul 2024.

Ethical considerations

The study was initiated after receiving approval from the Institutional Ethics Committee of KEM Hospital Research Center, Pune (Ethics Approval ref no: KEMHRC/RVM/EC/1302). Written informed consent was obtained from all the study participants.

Participants and recruitment

The study population included elderly individuals aged 60–80 years of either sex diagnosed with one or more noncommunicable diseases and prescribed three or more oral medications for at least a year. People who have access to a smartphone within the family throughout the day and have the knowledge of using a smartphone were enrolled. Exclusion criteria included: history of hospitalization in the past month; patients diagnosed with any mental or cognitive dysfunction (e.g., schizophrenia and Alzheimer’s disease); patients with an expected life expectancy of <1 year (severe disability and advanced stage malignant cancers); used pill organizers or PRA for improving medication adherence in the past. Participants with diverse education, gender, socioeconomic status, and noncommunicable diseases were enrolled to ensure that the study data were representative of the population.

Randomization

Participants who met all the study eligibility criteria and were willing to participate were randomized to one of the following three study groups: MPO (Group 1), PRA (Group 2), and MPO + PRA (Group 3). Excel-generated random code was used to detect 60 random participants from the available list of eligible elderly individuals. They were allocated to one of the three groups in a 1:1:1 ratio (n = 20 per group). This exercise was done separately for individuals aged 60–70 years and 71–80 years of age to ensure equitable distribution of both age strata in the participant groups.

Study interventions

A pill organizer that can sort medicines for up to 7 days using 4 compartments per day was utilized. The box had labels for each day and the timing of the day for ease of use. E.g., Monday – Morning, Afternoon, Night, and backup. Compartments for each day were colored differently and could be detached if needed. The MPO was selected based on the review of available pill organizers in the Indian market while considering availability, external features, cost, and ease of use. The use of the MPO, including its color-coding and labeling, was explained and demonstrated by the participants and their caregivers at the baseline.

An Android-based PRA, “MedSathi” was developed through an external vendor for the study. A beta version of PRA was used for the pilot study. It had provision for entering medicine regimes with the brand name, dose, frequency of dosing, type of formulation, and visual image of the medicine with an additional provision of maintaining a record for consumption of medicines. It featured customizable alarms and notifications tailored to the participant’s medication schedule. The PRA was installed by the study team with its interface and functionality demonstrated to participants and caregivers. Both the study interventions were provided for 3 months with Group 3 participants receiving both MPO and PRA.

Study outcomes

The study outcomes included the acceptability and feasibility of MPO and PRA and their combination from the perspective of participants and caregivers using mixed methods. The quantitative measures for usability included the System Usability Scale (SUS),[13] which was captured independently for the MPO and PRA. Qualitative feedback on acceptability and feasibility was assessed through focused group discussions (FGD) with the participants and in-depth interviews (IDIs) with caregivers. An exploratory endpoint included measuring changes in medication adherence using the Medication Adherence Rating System-5 (MARS-5)[14] and pill count.

Study procedures

At baseline, demographic data, and medical history including comorbidities, concomitant medications, source, and frequency of medication procurement were captured from all the participants. Medication adherence was assessed using MARS-5 at baseline and at the end of 3 months while SUS was administered at the endline to evaluate the acceptability and feasibility of the interventions. The pill counts were conducted over 7–15 days during the 2^nd or 3^rd month of the study after procurement of a new stock of medications. The participants were requested to retain empty blister packs or containers for all medications consumed.

The field research assistants conducted quarterly telephonic and monthly home visits to observe intervention usage, document medication changes, and provide technical support for MedSathi. Thirty IDIs with primary care providers and FGDs with participants for each intervention arm assessed facilitators and barriers to using MPO, PRA, and their combination. Tools prepared for IDIs and FGDs are provided in the supplements.

Statistical analysis

Quantitative data were initially recorded on paper forms, entered into REDCap electronic case record forms after source validation and quality checks, and analyzed using an anonymized clean dataset. Descriptive analyses utilized proportions, with group comparisons performed using the Chi-square tests. Responses were measured on a five-point Likert scale (1 = Always and 5 = Never), with higher scores indicating greater agreement. The SUS assessed the intervention’s usefulness, ease of use, and willingness to use, scored on a five-point scale (1 = strongly disagree and 5 = strongly agree). Analyses were conducted using Stata version 15.0 (Stata Corp LLC, College Station, Texas, USA). Qualitative data were audio-recorded using hand-held voice recorders. A Rapid Analysis Process (RAP)[15] with a deductive approach,[16] guided by predefined themes from IDI and FGD tools, was used to identify the barriers and facilitators of intervention use. The tools for IDI and FGD are included in the Supplementary Material ^{(283.3KB, pdf)} .

Results

Demographic characteristics

A total of 60 elderly individuals were randomly selected from 157 eligible participants in the study area with 58 completing the study and two dropping out [Figure 1]. Table 1 presents overall and groupwise demographic characteristics. Of the 58 participants, 37 (60.0%) participants were aged 60–70 years and 34 (56.7%) were men. A total of 49 participants (81.6%) were either illiterate or had received primary education. Irrespective of the study group, all participants had household access to smartphones throughout the day with 33 (55.0%) owning personal devices. All 60 participants were on three or more oral medications for at least 1 year and 37 (63%) taking medications for more than 5 years. Fifty-seven participants (95%) accessed private healthcare. Forty-eight participants (80%) were receiving medications for the treatment of hypertension and 47 (78.3%) for diabetes mellitus. The distribution of demographic characteristics was consistent across the study groups.

Figure 1.

Study flow chart. MPO = Manual pill organizer, PRA = Pill reminder app

Table 1.

Demographic characteristics

	Overall (n=60)	MPO (n=20)	PRA (n=20)	MPO + PRA (n=20)
Age, n (%)
60–70 years	37 (61.7)	12 (60.0)	12 (60.0)	13 (65.0)
71–80 years	23 (38.3)	8 (40.0)	8 (40.0)	7 (35.0)
Gender, no of males, n (%)	34 (56.7)	12 (60.0)	10 (50.0)	12 (60.0)
Education, n (%)
Illiterate	11 (18.3)	5 (25.0)	2 (10.0)	4 (20.0)
Less than primary education	22 (36.7)	5 (25.0)	8 (40.0)	9 (45.0)
Primary education	16 (26.7)	4 (20.0)	6 (30.0)	6 (30.0)
Secondary education	6 (10.0)	3 (15.0)	2 (10.0)	1 (5.0)
Higher secondary education	2 (3.3.0)	2 (10.0)	-	-
Diploma or graduation	3 (5.0)	1 (5.0)	2 (10.0)	-
Access to Smartphone	60 (100)	20 (100.0)	20 (100.0)	20 (100.0)
Own a smartphone	33 (55.0)	6 (30.0)	11 (55.0)	6 (30.0)
Years of treatment, n (%)
1–5 years	22 (36.7)	10 (50.0)	7 (35.0)	5 (25.0)
6–10 years	16 (26.7)	8 (40.0)	2 (10.0)	6 (30.0)
>10 years	22 (36.7)	2 (10.0)	11 (55.0)	9 (45.0)
Type of healthcare provider, n (%)
Private	57 (95.0)	17 (85.0)	20 (100.0)	20 (100.0)
Public	3 (5.0)	3 (15.0)	-	-
Number of ongoing oral medications, n (%)
Three tablets	44 (73.3)	10 (50.0)	11 (55.0)	12 (60.0)
Four tablets	6 (10.0)	2 (10.0)	3 (15.0)	1 (5.0)
Five or more tablets	21 (35.0)	8 (40.0)	6 (30.0)	7 (35.0)
Source for procurement of medicines, n (%)
Private	57 (95.0)	18 (90.0)	19 (95.0)	20 (100.0)
Public	3 (5.0)	2 (10.0)	1 (5.0)	-
Medical diagnosis, n (%)
Hypertension	48 (80.0)	17 (85.0)	17 (85.0)	14 (70.0)
Diabetes mellitus	47 (78.3)	17 (85.0)	15 (75.0)	18 (90.0)
Coronary heart disease	15 (25.0)	1 (5.0)	7 (35.0)	7 (35.0)
Hypercholesterolemia	7 (11.6)	3 (15.0)	1 (5.0)	3 (15.0)
Bronchial asthma/chronic obstructive lung disease	4 (6.6)	1 (5.0)	2 (10.0)	1 (5.0)
Thyroid disorder	7 (11.6)	4 (5.0)	1 (5.0)	2 (10.0)
Any other	20 (33.3)	8 (40.0)	7 (35.0)	5 (25.0)

MPO=Manual pill organizer, PRA=Pill reminder app

Feasibility and accessibility of manual pill organizer and pill reminder app through qualitative methods

Findings from the IDIs and FGDs in terms of feasibility, acceptability of MPO and PRA, perceived benefits and challenges, and impact on medication adherence are summarized in Table 2.

Table 2.

Feedback from the participants and their caregivers regarding the use of manual pill organizers and pill reminder app – Themes and subthemes

Themes	Manual pill organizer	Pill reminder app
Feasibility and ease of use	Easy to use despite being illiterate; Could be used independently; Local language labels are helpful, Appealing color; helped in systematic storage of medicines; easy to carry during travel	User–friendly interface and settings; local language is helpful; 2/3rd of participants could use independently
Perceived benefits	Helps to remember if a dose has been taken; reduces dependency on caregivers; and helps to keep stock of medicines	Helps in timely intake of medicines; no reminders needed from family members; prevents missing a dose
Adherence to the study intervention and willingness for long-term use	Got accustomed to using MPO; would continue to use them after the study	Used the intervention for most of the time during the study; Willing to use for long-term
Impact on medication adherence and health benefits	Apparent improvement in medication adherence; no immediate health benefits were reported	Apparent improvement in medication adherence; no immediate health benefits were reported
Perceived challenges	Initial difficulty in adjusting to MPO; assistance needed for a few elderly individuals with illiteracy and poor vision; Labels on the MPO came off for a few; Additional task to organize medicines	The technical challenge in using mobile apps for the illiterate; family assistance needed for 40% of people; Alarm malfunction in a few Android devices due to background killing of the app; difficulty distinguishing between alarm tone and caller tone; the alarm was not loud and clear in few phones
Suggested modifications	Larger sized MPO; printed labels instead of labelled stickers; concerns regarding exposed pills	Louder alarm tone requested; Alarm tone should be different from caller tone; Suggestion for recorded audio messages as the alarm tone; request for fewer alarms

MPO=Manual pill organizers

Manual pill organizer

All participants and their caregivers found MPO easy and convenient for storing medicines and 45 (75%) elderly participants could use it independently. Caregivers reported reduced dependency among participants to take their medicines, although some required assistance due to illiteracy or poor vision. A 36-year-old daughter-in-law commented, “The grandchildren help the participant to organize the box by reading the labels”.

Participants and caregivers found the MPO helpful for tracking missed doses, and addressing previous medication forgetfulness due to household chores. With the MPO, participants reported remembering to take medications. A 66-year-old female participant remarked, “The labels on the box help me remember to take my medicines.” While most noticed no immediate health improvement after using the MPO, a 70-year-old male participant shared, “Previously, I often forgot to take my blood pressure medication and felt the effects. Now, I take it routinely and have not fallen ill.” The participants viewed the MPO as a unique and integral part of their routine, expressing willingness for continued use.

The color of the MPO was found appealing and the use of the labels in the local language facilitated the medication schedule. A 30-year-old male caregiver remarked, “Earlier we used to write the timings of each medicine on the packet, the compartments of the pillbox have made it easier to remember the timings.” A 69-year-old male participant added, “Earlier my pills used to fall from packets and get dirty, box helps to store them neatly.” Participants also found the MPO to be a convenient size for travelling to their hometowns or temples ensuring they do not forget medicines. A 36-year-old female caregiver shared, “Last month, she travelled to Ayodhya and took the box with her. We had organized weekly medicines in the box.” Caregivers noted the MPO stores a week’s supply of medicines, providing an early alert when supplies run low. One of the 40-year-old male caregivers shared-“By checking the box, she realizes if she has missed any dose.”

Participants reported some challenges with MPO use. Initially, some found it difficult to transition from their habit of taking pills directly from packets. However, after a few days of routine use, they adapted to the new method. A 30-year-old daughter-in-law mentioned, “Initially it was difficult for him to break the habit, it was his routine to take meds from his pockets.” One participant’s caregiver refused to use the MPO, finding the task of organizing the weekly medicines to be an additional and confusing task. In addition, concerns were raised about storing unwrapped tablets in the MPO due to contamination risks, with some preferring a design accommodating blister pack. Suggestions included developing a larger MPO to fit blister packs and incorporating printed local language labels instead of stickers for better usability.

Pill reminder app

Caregivers and independent users reported the PRA as user-friendly with easily understandable local language. Most participants noted the alarm effectively reminded them to take their medication on time and alerted the household, ensuring no dose was missed. A 33-year-old caregiver remarked, “Sometimes she gets busy with housework, so the alarm helps remind her of the time. If she does not take the medicine on the first or second alarm ring, she will take it before the third one rings.”

Eight (20%) participants initially struggled with the PRA, requiring multiple demonstrations, particularly for updating the alarm. Sixteen (40%) required assistance from family due to illiteracy, unfamiliarity with Android phones or not owning a personal mobile phone. Alarm malfunction occurred on a few Android phones due to auto-settings restricting background app activity. Additional issues included irritation from repeated alarms, weak alarm tones, and confusion between phone ringtone and alarm sound. Despite these challenges, participants found the app effective for timely medication adherence and expressed willingness for prolonged use.

While most participants did not report any significant health changes, immediate positive effects were observed as participants began taking medications on time. A 67-year-old participant noted, “Earlier, my limbs would shake, and I would feel dizzy if I did not take my medicine on time. Thanks to the alarm, I now remember to take my medication on schedule and no longer feel dizzy.” Important feedback regarding PRA included using a unique alarm tone to distinguish it from other ringtones.

Combination of manual pill organizer and pill reminder app

Participants did not report any challenges using MPO and PRA together. On the contrary, MPO helped to systematically organize their medications, while the PRA alarm ensured timely administration. As one participant noted, “It has become easier with both interventions. The alarm helps me remember to take my medicine, and the box helps me store it.” Among the 20 participants who used both interventions together, 16 (80%) favored the MPO for its ease of use, citing difficulties with operating Android phones or frequently leaving them behind when outside the home. The MPO offered a convenient way to store and check for missed doses. Caregivers, however, preferred the PRA as it alerted them to the participant’s medication times, ensuring adherence to the schedule.

Usability of manual pill organizer and pill reminder app

The SUS scores for MPO and PRA are provided in Table 3. The scores provided indicate good usability in terms of ease of independent use for both interventions with more than 97% of participants having a SUS score of more than 68% which indicates good system usability.

Table 3.

System Usability Scale scores for manual pill organizer and pill reminder app

	MPO (n=39)	PRA (n=38)
I think that I would like to use this system frequently, median (IQR)	5 (5–5)	5 (4–5)
I found the system unnecessarily complex, median (IQR)	1 (1–1)	1 (1–1)
I thought the system was easy to use, median (IQR)	5 (5–5)	5 (5–5)
I think that I would need the support of a technical person to be able to use this system, median (IQR)	1 (1–2)	2 (1–3)
I found the various functions in this system were well integrated, median (IQR)	5 (5–5)	5 (5–5)
I thought there was too much inconsistency in this system, median (IQR)	1 (1–1)	1 (1–1)
I would imagine that most people would learn to use this system very quickly, median (IQR)	5 (5–5)	5 (5–5)
I found the system very cumbersome to use, median (IQR)	1 (1–1)	1 (1–1)
I felt very confident using the system, median (IQR)	5 (5–5)	5 (5–5)
I needed to learn a lot of things before I could get going with this system, median (IQR)	1 (1–2)	2 (1–2)
Individuals with good system usability, n (%)	39 (97.44)	38 (97.37)

IQR=Interquartile range, MPO=Manual pill organizer, PRA=Pill reminder app

Impact on medication adherence

Table 4 provides the medication adherence using MARS-5 scores and pill count. The overall score for MARS-5 marginally changed from baseline to endline in all three groups and there was marginal improvement in the medical adherence as defined by % of individuals with MARS-5 >22 in the MPO and combination group. Interestingly, at baseline, 52%–65% of participants reported that they never forget to take medicines which improved to 90%–100% at the end of the intervention indicating the usefulness of both interventions. The pill count counted during month 3 of the intervention showed more than 80% adherence in 95%–97% of participants which is consistent with the adherence reported in terms of MARS-5.

Table 4.

Medication adherence using medication adherence rating system - 5 and pill count

	MPO (n=20)	PRA (n=19)	MPO + PRA (n=19)
MARS-5
Baseline (mean±SD)	24.2±1.15	24.42±0.61	24.11±0.99
Endline (mean±SD)	24.4±0.99	24.84±0.50	25±0
Adherent (>22)
Baseline, n (%)	17 (85)	19 (100)	18 (94.74)
Endline, n (%)	19 (95)	19 (100)	19 (100)
Never forget to take medicines
Baseline, n (%)	13 (65)	10 (52.63)	10 (52.63)
Endline, n (%)	18 (90)	18 (94.74)	19 (100)
Pill count
≥80% adherence, n (%)	18 (94.74)	18 (94.74)	19 (100)
Adherence (mean±SD)	96.09±6.04	95.8±11.63	97.14±3.6

MPO=Manual pill organizer, PRA=Pill reminder app, SD=Standard deviation, MARS-5=Medication adherence rating system - 5

Discussion

The findings of this study show that both MPO and PRA are feasible to be deployed among elderly individuals from the rural areas and the interventions are acceptable to elderly members and their families. The qualitative exploration shows that the MPO is easy to use and convenient, even for those with low education and limited smartphone literacy. Similar to the findings from another study, the most frequently cited benefit of the MPO was its ability as a visual reminder, allowing participants to check for missed doses.[10] The labels on the MPO helped maintain track of their medication schedules. The MPO also helped in the organization of medications and their carriage during travel. Other studies on pill organizers amongst elderly participants showed 86.9% found them helpful for remembering dosage times, while 91.8% reported they assist in recalling the correct dosage amount.[17]

PRA was found to be acceptable among the elderly and more so among caregivers where the major benefits included the user-friendly nature of the PRA and the use of regional language. All PRA users received audible and visual reminders and notifications tailored to their medication schedules which helped them in the timely intake of medicines.

No challenges were reported during the combined use of MPO and PRA. The participants and caregivers perceived them as complementary, suggesting their combined use offers a more organized and reliable medication management system than individual interventions.[18] The findings from previous research on the efficacy of mobile application reminders indicate the use of technologies alone is insufficient to improve adherence significantly.[19,20,21] The results have been more encouraging when the app reminders are used in combination with in-person communication imparting.[21]

Despite a few challenges with the PRA, the interventions were found to be feasible for rural elderly populations. Technical issues, such as alarm malfunctions and weak tones due to auto-settings on certain android phones were addressed during the study, improving the technology. Multiple demonstrations and caregiver involvement are necessary for elderly users to independently operate the PRA. Previous studies on health-related applications have highlighted similar difficulties, with complex interfaces that are challenging for the elderly to navigate.[22,23] Based on the feedback, the PRA was modified with a standard alarm tone, dashboard support for installation issues, and an in-house server using open-source technology. The majority of participants expressed a willingness to continue using the interventions poststudy, perceiving them as beneficial. Presently, the application is being deployed in a large-scale randomized trial to evaluate the effectiveness of both MPO and PRA on medication adherence and will be available in the Google Play Store for larger public use after the study completion.

The study provides pilot evidence on the effectiveness of the interventions among Indian elderly people in reducing medication nonadherence due to forgetfulness as assessed using MARS-5. These results align with an RCT in the United States, where app users demonstrated significantly higher adherence compared to the control group (43% vs. 10%).[24] Another study found a significant positive correlation between pillbox use and medication adherence, showing that patients who regularly used a pillbox had a 28% higher adherence rate compared to those who did not.[25] A meta-analysis of 22 RCTs involving 3152 patients showed electronic reminders including short message service reminders, pager reminders, and electronic alarm device-triggered reminders significantly improved adherence (pooled Cohen’s d = 0.29, 95% confidence interval 0.18, 0.41).[26] However, the study duration and sample size were inadequate to detect the changes in adherence using pill count methods. Nonetheless, it helped standardize pill count methods in rural India without causing any influence on the medication-taking behavior of the participants.

Conclusion

The study demonstrates that MPOs and indigenously developed PRA are acceptable among the Indian rural elderly population. The MPO emerged more user-friendly, being favored for its simplicity, effective dose tracking, and independence from technology. The PRA was valued for its timely reminders, though technical and usability issues limited adoption. Using both tools together was perceived synergetic improving storage and timely intake without any difficulty in concomitant use. The results show the feasibility of using MPO and PRA either alone or in combination in future larger studies.

Conflicts of interest

There are no conflicts of interest.

Supplementary material

Tools used for FGD and IDI.

Funding Statement

The study was done as the part of the ICMR national task force on the safe and rational use of medicines (ICMR SRUM NTF) and was funded by the Indian Council of Medical Research, New Delhi (Sanction letter no: SRUM/2023/BMS/Part 6/Aditi Apte).