Table 2.

Refined CMOCs derived from testing and consolidating IPTs against the evidence, guided by SCT

SCT component	CMOC no.	Refined CMOC	Supporting quotes and data source
Practitioners (Knowledge, skills, beliefs about capabilities)
Capability	1	If Practitioners lack understanding of their older person’s cultural backgrounds (C), then it reduces trust (M), leading to non-adherence and poorer communication (O).	14 included studies supported this CMOC [47–52, 54, 56, 59, 60, 62, 63, 65, 66]. The lack of cultural competence negatively impacts the practitioners’ ability to engage older people effectively. A practitioner’s insight highlights this challenge “If they are struggling to understand that person, or if they don’t understand their background, then they are not going to cater their treatment towards what’s best for them” [54]. This lack of understanding often results in poor communication and mistrust. For instance, a patient’s remark, “I let him prescribe me my medication but apart from that I never consult him” [60], suggests that perceived cultural incompetence or indifference may contribute to reduced patient engagement and adherence.
Intention and shared decision-making	2	If the practitioners create an environment where older people from EMCs feel heard and trusted (C) then active engagement in shared decision-making will be enhanced (M), leading to greater satisfaction (O).	We identified two studies that provided support for this CMOC [51, 66]. When older people from EMCs feel heard and trusted, their engagement in shared decision-making significantly increases, which is critical for effective MO. Positive outcomes have been observed when practitioners actively involve patients in discussions about their prescribed medications, reinforcing a sense of ownership and control over their health. For instance, participants who reported being part of the decision-making process expressed greater satisfaction and a stronger commitment to adhering to their prescribed medication regimens [51]. However, this process is often challenged by systemic barriers such as the involvement of multiple specialists and poor communication between providers, which can lead to confusion and disengagement. As one participant noted, “A central barrier to shared decision-making was having too many doctors prescribing the medications, too many pharmacies filling the prescriptions, and no sharing of information between those entities or with the patient” [51]. Despite these challenges, those who felt supported by their practitioners were more likely to stay engaged and achieve better health outcomes, highlighting the importance of clear communication in MO.
Patients (Health literacy, Social Influence, beliefs about consequence)
Cultural Stigmas	3	If cultural stigmas related to mental health are presented (C) then it could lead to avoidance of necessary medications and poorer communication with the practitioners (M), leading to issues such as unmanaged symptoms or worsening of the condition (O).	This CMOC was developed based on 11 studies [49–51, 53–55, 57, 61–64]. That emphasise how cultural norms and stigmas could influence health behaviours within these populations, particularly regarding mental health. For example, within Arab communities, there is resistance to engage in mental health treatments due to cultural perceptions of mental illnesses “I know somebody whose doctor wants her to be on antidepressants for a different mental issue, and she hasn’t begun the medication. It’s hard for her to accept the fact that she needs to take the antidepressants, and I feel like it’s a cultural thing” [57]. Similarly, in South-East Asian communities, there’s a chance to suppress symptoms of depression and anxiety because these conditions are associated with shame and embarrassment. As one healthcare professional noted, patients often “suppress their symptoms of depression and anxiety due to cultural beliefs of shame and embarrassment” [54]. Another participant added, “Patients come with a physical problem and when you dig down into it, you realise that there’s mental health problems underlying it… and there’s an under-diagnosis of dementia and cognitive problems in some minority populations too”. Moreover, the stigma is so powerful that it can lead to avoidance of medications, particularly when the practitioner is from the same ethnic background. As one participant said, “I didn’t want him [a doctor of the same ethnicity] to have access to the list of depression medications I take… it is not something I wish my community [members] to know” [54]. This collectively shows how cultural stigmas can lead to poor communication, non-adherence, and ultimately, ineffective MO.
Communication needs	4	If the older person experiences a language barriers and cultural differences (C) then the integration of bilingual support and culturally sensitive communication strategies (M) significantly improves their comprehension and engagement, leading to better adherence, and greater overall satisfaction (O).	Language barriers were identified in 11 included studies as being significantly obstructing healthcare engagement among EMCs [48, 49, 52–54, 56, 60–62, 64, 66]. The complexity of medical terminology and cultural context can often get lost in translation, impacting patient satisfaction and medications adherence. For instance, a provider working with South Asian patients noted, “Sometimes the way that we describe symptoms… may not translate into the communities or other languages… it can get lost” [54].
Information overload	5	If the older person gets overwhelmed by the medication information and a lack of personalised communication (C) then this leads to mistrust and anxiety about prescribed medications (M), resulting in poor adherence and suboptimal health outcomes (O).	9 included studies supported this CMOC [47, 48, 50, 52, 53, 56, 59, 62, 66]. Older people from EMCs often find medication information overwhelming and irrelevant, leading to non-adherence. One patient expressed, “They said the drug information was too overwhelming, discouraged them from taking medicine” [48]. The lack of personalised communication fosters mistrust, resulting in poor medication adherence and worsening health conditions.
Religious Beliefs	6	If older person view health through the lens of their religious beliefs (C) then they are less likely to engage with their practitioners about medications that conflicts with these beliefs (M), leading to suboptimal health outcomes (O).	Patients from diverse religious backgrounds interpret and manage their health through their religious beliefs, which can impact their willingness to accept medications. For example, a Muslim patient might refuse medications containing non-halal ingredients: “The doctor focuses only on the symptoms and the suitable medicine for helping me, but no one focuses on the medicine, if it is related to certain foods, then this can be a big problem for Muslim culture and Muslim religion” [64]. Moreover, another Muslim participant shared, “Religious belief is not going to stop me taking any medications, actually religious [beliefs] tell you [to] take care of yourself, so that’s why I have to take the medicine … Yeah, because I mean they ask you to take care of yourself. And if you take care of yourself you will be able to take care of other people” [59]. A Sikh participant highlighted the importance of healthcare professionals respecting and understanding different cultural and religious backgrounds: “Sometimes (healthcare professionals) don’t understand – I told them I’m a Sikh and I’m an Indian background, so he knew I could have the certain medicine that maybe the Muslims can’t have with it being not Halal ingredients, but he didn’t understand it… to me that is a big, big difference… this is why it is important for us to feel that they (healthcare professionals) respect and know our cultures and our backgrounds” [64].
Traditional Health Beliefs	7	If older person holds traditional cultural health beliefs (C), then this can significantly influence their preferences for and adherence to traditional versus contemporary medicines (M), leading to varying level of engagement with contemporary medicines.	8 studies supported that cultural and ethnic backgrounds shape patient preferences for traditional or contemporary medicine [50, 52, 56, 57, 59, 60, 64, 67]. For instance, A participant shared, “To me, medicine is also a poison. So don’t depend on too much. I believe that medicine is not really good for the health. It’s good for the sickness, but it’s not good for the health” [52]. This perspective shows a preference for traditional practices due to concerns about the perceived harms of Western medicines. Additionally, some patients may perceive traditional medicine as more accessible and effective due to their familiarity with these medications. For instance, one participant stated, “Sometimes it could also be about trust if the medication is from your home country… You have faith in the place you come from, and now you come to a new country and their medication does not work as well” [60].
System and the organisation (environmental context, resources, intention)
Resource Constraints	8	If appointment times are too short and there are remote communication barriers (O) then the interactions between older person from EMCs and their practitioners are compromised (M), leading to miscommunication and incomplete understanding (O).	Systematic barriers as supported by 6 studies, such as limited appointment times and remote communication challenges, disproportionately affect EMCs. These barriers restrict the quality of patient-provider interactions [47, 50, 51, 54, 64, 66]. For instance, one provider noted the difficulty in accommodating patients with limited English: “We try to book a double appointment if we have an interpreter… it’s difficult for them to access services, so when they do, then they often have lots of problems that they want to discuss…” [54]. Older people from EMCs often require longer appointments due to language barriers and the need for cultural sensitivity in discussions. These factors require more time for effective communication and understanding, to ensure patients are fully engaged and their health needs are appropriately addressed. Also, a lack of sufficient consultation time can lead patients to rely on their own knowledge or alternative treatments due to inadequate information provided during appointments. As noted, “due to limited consultation time, healthcare practitioners may be unable to provide information to patients who rely on their own knowledge around illnesses and prefer to use alternatives to medication treatments” [47]. The need for interpreters and the challenges of remote communication further complicate interactions. One participant described the benefits of in-person consultations, emphasising that “it’s not the same when you talk on the phone… sometimes I need to point to the box, want to describe my answer like that, or want to point to the things, but I cannot if it is talking on the phone… like my legs when I have the swelling in my ankles” [64]. Additionally, limited patient-care provider interaction time makes detailed discussions harder. As reported, “there is not enough time to talk with staff in detail” and “limited patient-care provider interaction and limited time availability are reported” [50]. Also, participants mentioned that remote consultations, while convenient, often fell compared to in-person visits. They found it harder to pick up on nonverbal cues and discuss detailed medication information effectively. This lack of personal interaction made it challenging for healthcare providers to ensure that patients fully understood their medications, which could negatively impact medication adherence, particularly for older people from EMCs, as one participant said, “It’s not the same when you talk on the phone… I need to point to the box, want to describe my answer like that, or want to point to the things, but I cannot if it is talking on the phone” [64].
Experience-Based Adaptation	9	If the older person has previous experiences with different healthcare systems (C) then their understanding and trust may be shaped by those experiences, influencing their expectations and behaviors (M), which could lead to either enhanced or diminished engagement and adherence. (O).	As per the 5 included studies, EMCs bring diverse healthcare experiences from their home countries, influencing their perceptions and interactions with the new healthcare system [49, 54, 62, 64, 65]. For instance, factors such as how long they’ve been in the UK, whether they were born in the UK, and whether they recently arrived were discussed as barriers impacting a person’s understanding and expectations relative to their health [64]. Patients who have recently arrived might be used to different healthcare systems, such as private healthcare or none at all, depending on their country of origin [64]. For example, one participant from India, initially questioning about medication reviews, found them beneficial after understanding their purpose: “In England, it is different with having the review, then you learn to know much more and learn how such-and-such medicine works… you can check these things every year, which I like better and I understand much more of the medicines now” [64]. Moreover, healthcare professionals may not always realise that patients are unfamiliar with certain practices, such as medication reviews, from their home countries. Better explanations can help these patients understand the benefits, as one participant noted: “They maybe explain it better for us… then we can know to understand the medicines review is existing and why it is good for us patients to have it” [64]. Additionally, trust issues can arise when patients prefer medication from their home countries due to familiarity and perceived efficacy: “Sometimes it could also be about trust if the medication is from your home country… You have faith in the place you come from, and now you come to a new country and their medication does not work as well” [62]. Furthermore, the role of pharmacists and cost considerations in countries like Pakistan can differ significantly from the UK, influencing patients’ perceptions and interactions with the healthcare system: “In Pakistan, the pharmacists – well with them you don’t even need to go to the doctor… The pharmacist has their own medicines, tablets, injections, everything, and they know how much to give of everything” [49].
Informal carers (Health literacy, Social Influence, beliefs about consequences)
Support and Engagement	10	If cultural expectations lead family members to take on caregiving responsibilities (C) then its prompt behaviours like active engagement (M). leading to improved communication and understanding (O).	Evidence from 13 studies supports this CMOC [49, 50, 53–58, 60–62, 65, 66]. In EMCs, family members often take on significant roles in patient care due to cultural expectations and language barriers. This active engagement can lead to improve the communication and the understanding. Participants frequently discussed the necessity of family members in translating during consultations. For instance, one participant noted, “patients of South Asian or Arab backgrounds… are more likely to have more input from their children, which can facilitate processes like medication reconciliation” [54]. Living with extended family provides necessary social support, helping patients navigate healthcare systems and adhere to medications. As one participant shared, “Sometimes, there are too many people in the home helping, making it confusing at times. However, for most patients, extended family and living in a close-knit community provided needed and valued social support” [61] Family members also act as essential Facilitators in communicating and interpreting the clinical information. This dynamic help in improving communication and understanding. As noted, “family was identified as a key resource to all patients in coping with illness and navigating healthcare, from planning visits to understanding clinical information” [65] Moreover, active family involvement helps bridge communication gaps. This is crucial, as another participant explained, “Sometimes we experience that the relatives take responsibility for the patient and are a kind of spokesperson [for the patient]” [62].
Caregiver Stress	11	If limited access to primary care services and reliance on informal caregiving (C), then this can lead to increased caregiver stress and emotional strain (M), resulting in caregiver burnout (O).	4 included studies supported this CMOC [54, 58, 61, 64]. Limited access to primary care services often forces older people to rely heavily on informal caregiving. This dynamic is particularly common in EMCS, where family members commonly take on significant caregiving roles. For instance, participants from South Asian and Arabs backgrounds frequently rely on their children for medication management and healthcare navigation, as highlighted by a pharmacist who noted that “involving family members can facilitate processes like medication reconciliation” [54] However, this reliance on family members can lead to increased stress and emotional strain. One participant shared that when relatives are responsible for translating sensitive medical information, it can be problematic and add to their stress [54]. Additionally, when caregivers are busy with work or other responsibilities, managing medical appointments and care can become overwhelming, as illustrated by a caregiver who had to accompany their non-English-speaking mother to appointments [61]. This intense involvement often leads to caregiver burnout. The emotional and physical toll of caregiving without adequate support can result in negative health outcomes for both the caregiver and the patient. For example, a participant reported significant stress due to taking on extensive caregiving duties, which eventually led to feelings of depression and burnout [58].

The final middle-range programme theory

Older people from EMCs experience multiple, interrelated barriers when it comes to managing multiple medications, due to a complex interaction between cultural beliefs, language differences, and systemic factors within primary care settings

To achieve MO for these communities, culturally tailored strategies that address these barriers, such as integrating bilingual support, providing culturally sensitive consultations are needed

For practitioners, a lack of cultural competence can reduce trust and engagement, which, if not addressed, results in poor adherence and health outcomes. Similarly, old people’ traditional health beliefs and religious values heavily influence their medication preferences, which often lead to hesitancy or resistance to certain prescribed medications.This requires practitioners to be mindful of not only the cultural contexts, but also the environmental constraints, such as limited appointment times and remote consultations