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. 2026 Apr 16;15:40. Originally published 2026 Jan 9. [Version 2] doi: 10.12688/f1000research.175364.2

MEDICATION ADHERENCE AMONG ELDERLY PATIENTS RECEIVING HEALTH CARE SERVICES IN WATERBERG DISTRICT, LIMPOPO PROVINCE: A Qualitative phenomenological study protocol

T Mavhungu 1,a, AG Mudau 1,b, TR Lebese 1,c
PMCID: PMC13090761  PMID: 42004857

Version Changes

Revised. Amendments from Version 1

The topic of the study protocol is adjusted to: Medication adherence among elderly patients receiving health care services in Waterberg district, Limpopo province: A Qualitative phenomenological study protocol abstract: study population, study setting, sample size and sampling approach specified. Introduction: modified, irrelevant information omitted. The gap and aim of the research are identified. Objectives: The first objective is modified to: to investigate medication adherence experiences among elderly patients receiving health care services at a selected hospital in the Waterberg district, and to identify barriers and facilitators influencing medication adherence. study design is specified: descriptive phenomenological  The sample size is anticipated and justified with (Guest et al.,2026) interview guide: translation of the interviews to sepedi and back translation for validation is mentioned Data analysis: the protocol specified the method used to analyse the data, which is that of Braun & Clarke (2006).  A description of how disagreements in coding interpretation will be resolved is mentioned. strategies to ensure trustworthiness, such as credibility, transferability, dependability, and confirmability, are explained. Ethical considerations: it is explained how confidentiality will be maintained and how participants will be identified. Discussion: expected contributions are discussed. Competing interests are disclosed

Abstract

Introduction

Medication adherence among elderly patients is crucial for maintaining their health and well-being; many face challenges that hinder their ability to follow prescribed regimens. This study aims to investigate the experiences to identify barriers and facilitators influencing adherence and to describe the perceptions of medication adherence among the elderly. Health care professionals can tailor targeted intervention to the challenges faced by the elderly to improve medication adherence among elderly patients. Study design this is a qualitative phenomenological study protocol.

Methods and analysis

The target population for this study comprises elderly patients aged 60 years and above residing in the Waterberg District who have been diagnosed with at least one chronic disease and are receiving healthcare services. This study will be conducted in FH Odendaal hospital, in the Waterberg district. The inclusion criteria for this study are elderly patients aged 60 years or above who have been diagnosed with at least one chronic disease and can provide informed consent and have been using medication for at least three months. The researcher anticipates enrolling 15 to 30 participants, stopping when saturation is reached, and no new themes emerge. The data saturation point will determine the final number of participants, ensuring that the diversity and depth of participants’ understanding are adequately captured. The researcher will use purposive sampling. Data will be collected through interviews with two central questions, and probing will be used based on the participants’ responses. The collected data will be analysed thematically.

Ethics and dissemination

The proposal has been approved by the Research Ethics Committee of the University of Venda. Permission to conduct the study will be obtained from the Limpopo Department of Health, the Waterberg District, and the selected hospital. Autonomy, confidentiality, care for the vulnerable group, and informed consent will be maintained. Key findings will be disseminated through academic publications, community settings, policymakers, and healthcare providers in a selected hospital.

Keywords: Keywords: chronic diseases, elderly, Medication adherence

Introduction

Medication adherence among elderly patients living with chronic diseases continues to be a significant challenge in health care. Medication adherence refers to the extent to which a patient’s behaviour aligns with optimal medication use, and it is a key factor in achieving therapeutic goals and improving patient outcomes ( Specialist Pharmacy Service, 2023). Medication nonadherence is associated with poorer health outcomes when an individual fails to achieve the expected health benefits from medications related to a specific illness.

The World Health Organisation (2025) estimates that globally, the proportion of people aged 60 years or older will double by 2050. Most older people reside in low- and middle-income countries, such as South Africa. Population ageing is a public health concern that could negatively impact the South African economy and health system if the government fails to prepare for this change ( Sibanda et al., 2021). The elderly population is growing rapidly in many countries, with an estimated total of 2.37 billion people aged 65 years or older globally by 2100 ( Hung et al., 2020). The population of South Africa grew by 19,8% between 2011 and 2022. In 2022, the estimated total population of South Africa was 62,027,503, including more than 5 million people aged 60 or older, which represented a 9,2% share of the overall South African population. The number of older persons increased across all provinces; in Limpopo, the total population was 6,572,721, comprising 6.9% of the older population (65 years and above). The Waterberg district (Modimolle-Mookgophong municipality) had a total population of 130,113, of whom 9.8% were elderly ( SA STATS, 2023).

In South Africa, approximately 85% of the elderly population has at least one chronic health condition, and 60% have two or more ( SA STATS, 2023). This demographic shift drives a growing chronic burden, raising demand for long-term medication use. However, about 50 % of the elderly struggle with adherence ( Nguyen et al., 2024), and non-adherence contributes to readmissions and mortality, especially where polypharmacy and system constraints intersect. Studies describe patient, drug, and health system factors, but no known study has explored older patients’ perspectives and experiences of medication adherence in the Waterberg district. This study, therefore, aims to investigate medication adherence perspectives and experiences among elderly patients in the Waterberg district.

Objectives

  • •

    To investigate the experiences of medication adherence among elderly patients receiving health care services in a selected hospital of the Waterberg district to identify barriers and facilitators influencing adherence.

  • •

    To describe the perception of medication adherence among elderly patients receiving health care services in a selected hospital in the Waterberg district.

Materials and methods

Study design

This qualitative study will employ a descriptive phenomenological design to explore medication adherence among elderly patients receiving healthcare services in a selected hospital in the Waterberg district. This design enables an in-depth understanding of the experiences and perceptions of medication adherence among elderly patients. This approach allows for capturing the essence of lived experiences without adding interpretation, aligning with the way they describe their perceptions.

Population

The target population for this study comprises elderly patients aged 60 years and above residing in the Waterberg District who have been diagnosed with at least one chronic disease and are receiving healthcare services.

Inclusion criteria

The inclusion criteria for this study are elderly patients aged 60 years or above who have been diagnosed with at least one chronic disease and can provide informed consent and have been using medication for at least three months.

Exclusion criteria

The exclusion criteria encompass patients with severe cognitive impairment or mental illness issues that hinder interview participation.

Sampling

Purposive sampling will be used to select participants who meet the inclusion criteria until data saturation is reached, at which point no new themes or insights emerge. The researcher will purposively select participants with varying genders, any chronic disease, a treatment duration of at least 3 months, and any cultural background to capture diverse cultural beliefs.

Sample size

The researcher anticipates enrolling 15 to 30 participants, stopping when saturation is reached, and no new themes emerge. As suggested by Guest et al. (2006). The data saturation point will determine the final number of participants, ensuring that the diversity and depth of participants’ understanding are adequately captured.

Interview guide

The primary data collection instrument for this qualitative study will be an unstructured interview guide with two central questions, developed to explore the perceptions and experiences of elderly patients with chronic disease(s) regarding medication adherence.

The interview guide will be developed based on an extensive literature review on medication adherence and age-related factors influencing adherence behaviours. The questions will focus on exploring the experiences and describing the perceptions of medication adherence among elderly patients.

Probing will be used to better understand medication adherence among elderly patients. The researcher will ensure that they understand the participant by paraphrasing, encouraging the participant to elaborate more, and listening attentively. The interview guide will be translated into the local language, Sepedi, to ensure that all participants can understand the questions clearly and contribute actively during data collection, thereby minimising language barriers and promoting effective communication.

Prior to the main data collection, a pretest will be conducted in a private setting at a designated hospital. A small subset of 2 to 3 elderly patients who will not participate in the main study but who meet the inclusion criteria will be recruited. The pretest results will be analysed to determine the clarity, relevance, and general usefulness of the interview guide. Based on the feedback and ideas, changes will be made to improve the interview guide’s questions, wording and flow.

The researcher will conduct the interviews, as they have expertise with the patients as a healthcare professional. To minimise bias and power dynamics, the researcher will engage in reflective journaling to acknowledge and set aside preconceptions, and will use open-ended, neutral questions to encourage participants’ led narratives and create a comfortable, non-judgmental space.

Recruitment

The researcher will recruit participants from the outpatient department in the selected hospital. The researcher will greet and conduct introductions to patients in the outpatient department. Explain the purpose of being there and explain the aim, objectives, and target population of the study. Then ask for patients who fit the criteria and are willing to participate. Volunteer participants will be asked to come to a secluded area. A brief session will be done to explain the research objectives, procedures, and ethical considerations. Participants will be asked to sign a consent form, and they will be told that they can withdraw from participating at any time without prejudice. Clarification of any questions or concerns raised by participants will be provided. During data collection, field notes will be documented through written notes. To capture non-verbal expressions, such as gestures, facial expressions, and body language, researchers will take detailed observational notes immediately following interactions. An audio recording will be used to capture an interview, and the recorded data will be transcribed verbatim by the participant.

Ethical consideration

Ethical approval for this study was obtained from Research Ethics Committee of the University of Venda (clearance number: FHS/25/PH/15/1509). Permission to conduct a study was obtained from the Limpopo Department of Health, the Waterberg District, and the management of the selected hospital (FH Odendaal). This study will adhere to ethical guidelines concerning human participants. Informed consent will be obtained, participants’ confidentiality will be maintained by ensuring that all the information collected, including audio recordings and transcripts, remains confidential, data will be stored securely in password protected electronic files and locked physical cabinets, care for vulnerable groups will be considered, and participants’ identities will be protected by assigning unique codes or pseudonyms to all collected data. Participants may withdraw from the study at any time without prejudice.

Data analysis

Thematic analysis will be used to interpret the qualitative data collected from the interviews. Analysis will follow Brauna & Clarke (2006) six-phase thematic analysis approach. This method enables the identification, analysis, and reporting of themes within the data, providing a rich understanding of the participants’ experiences and perceptions. The primary researcher will perform coding, and the second researcher will independently code a subset of transcripts to enhance dependability. Disagreements in coding or theme interpretation will be solved through discussion and consensus. Qualitative data analysis software such as NVivo may be used to facilitate data coding and organisation, ensuring systematic analysis and traceability of themes. Trustworthiness will be maintained by implementing the following: Credibility by checking on participants throughout the data collection process, Dependability by doing an audit trail to document each step, Confirmability by practising reflexivity through reflective journaling throughout the research process to minimise research bias and Transferability by doing a detailed description of the research context, participants’ characteristics and methodology.

Procedures

TRANSCRIPTION

All interviews will be transcribed verbatim to ensure accuracy and facilitate detailed analysis.

FAMILIRAZATION

The researcher will thoroughly read and re-read the transcripts to immerse themselves in the data.

CODING

Initial codes will be generated systematically across the dataset, focusing on meaningful segments related to medication adherence.

THEME DEVELOPMENT

Similar codes will be collected into tentative themes that capture significant aspects of participants’ experiences.

REVIEWING THEMES

Themes will be reviewed and refined to ensure they accurately reflect the data and are distinct.

DEFINING AND NAMING THEMES

Clear definitions will be developed for each theme, and illustrative quotes will be selected to exemplify key findings.

REPORTING

The final themes will be interconnected to provide a comprehensive narrative on medication adherence among the elderly with chronic diseases.

Dissemination

The researcher will prepare a comprehensive research report to be submitted to a peer-reviewed journal, focusing on public health, the organisation of community meetings, or collaboration with local health communities to communicate findings. The researcher will conduct a presentation session or workshop for healthcare providers at FH Odendaal Hospital and local clinics to share the findings. The researcher will also prepare a policymakers’ brief summarising key findings and recommendations.

Discussion

This study will address the identified gap of the absent of known study in investigating the elderly patients’ own perspectives and experiences of medication adherence in the Waterberg district. The findings are expected to deepen insight into their experiences and perceptions. The results are anticipated to assist elderly patients living with chronic diseases and their families. This study is also anticipated to recommend strategies to policymakers to design targeted interventions and to help the government reduce health care costs associated with hospital readmissions, emergency room visits, and the need for expensive medications due to medication non-adherence.

Study status

This study is currently an ongoing process of collecting data. Permission to conduct research from the Limpopo Department of Health, Waterberg district, and the selected hospital has been obtained.

Acknowledgements

I would like to express my sincere gratitude to my supervisor, Dr. Mudau AG, and co-supervisor, Prof. Lebese TR, as well as to the elderly participants who contributed to this research, and to the healthcare providers at the selected hospital.

Funding Statement

The University of Venda Research and Publication Committee will pay the publication fee. They have not made any contribution in preparing this article

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

[version 2; peer review: 1 approved

Data and software availability

Data supporting this study will be made available upon request after the research is completed, ensuring adherence to ethical standards. Data will be available from the corresponding author thomphomavhungu4@gmail.com on reasonable request. Access will be granted to researchers who provide clear research purpose and methodology, agree to comply with the University of Venda’s data sharing policies and ethical approval.

Underlying data

No data is associated with this article.

References

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F1000Res. 2026 Apr 17. doi: 10.5256/f1000research.198298.r475700

Reviewer response for version 2

Mohammed Alfaqeeh 1

Thank you for the opportunity to review the revised manuscript. The authors have addressed the previous comments well and have significantly improved the clarity and methodological rigor of the study protocol. The revised version is clearer, more comprehensive, and suitable for indexing in its current form. No further comments.

Is the study design appropriate for the research question?

Yes

Is the rationale for, and objectives of, the study clearly described?

Partly

Are sufficient details of the methods provided to allow replication by others?

Partly

Are the datasets clearly presented in a useable and accessible format?

Not applicable

Reviewer Expertise:

Public health researcher trained in epidemiology and health economics, focusing on communicable and non-communicable diseases, vaccine policy, ageing populations, and evidence-based health decision-making. Experienced in systematic evidence synthesis, pharmacoeconomic modelling, and translating research findings into policy recommendations.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

F1000Res. 2026 Apr 16. doi: 10.5256/f1000research.193343.r452694

Reviewer response for version 1

Yosra Alhindi 1

General Comments:

This study protocol addresses an important and timely public health issue—medication adherence among elderly patients with chronic diseases. The topic is highly relevant given the increasing burden of multimorbidity and population ageing, particularly in low- and middle-income settings such as South Africa.

The manuscript is generally well structured, and the use of a qualitative phenomenological design is appropriate for exploring lived experiences and perceptions of medication adherence. However, several aspects of the manuscript require clarification and strengthening to enhance methodological rigor, clarity, and scientific contribution. In its current form, the manuscript is potentially publishable after major revisions.

Major Comments:

1. Title:

The title clearly reflects the topic and population; however, it lacks methodological transparency. Since this is a study protocol employing a qualitative phenomenological design, the study type should be explicitly stated.

Recommendation:

Revise the title to include terms such as “A Qualitative Phenomenological Study Protocol.”

2. Abstract:

The abstract provides a basic overview but lacks sufficient methodological detail and includes an overstatement of expected outcomes.

- The study design is not explicitly mentioned.

- The methods section is too brief.

- The statement implying improvement in adherence rates is inappropriate for an observational qualitative study.

Recommendation:

- Clearly state the study design.

- Include population, sample size, and data collection methods.

- Rephrase outcomes to reflect exploration rather than impact.

3. Introduction:

The introduction provides relevant background but requires refinement:

- Some sections are repetitive.

- The discussion of noncommunicable diseases is overly broad.

- The research gap is not clearly articulated.

Recommendation:

- Reduce redundancy.

- Focus specifically on medication adherence in elderly populations.

- Clearly define the knowledge gap.

4. Objectives:

The objectives are appropriate but somewhat generic.

Recommendation:

- Align objectives with phenomenological inquiry.

- Include exploration of barriers and facilitators.

5. Methods:

a. Study Design:

Clarify whether the phenomenological approach is descriptive or interpretive and justify its use.

b. Sampling Strategy:

Specify the sampling method (e.g., purposive sampling) and explain participant selection.

c. Inclusion Criteria:

Include a requirement that participants have been on medication for a minimum duration (e.g., 3 months).

d. Data Collection:

Provide more detail on interview domains and whether the interview guide will be pilot-tested.

e. Data Analysis:

Specify the analytical framework (e.g., Braun & Clarke thematic analysis) and describe how rigor will be ensured.

f. Ethical Considerations:

Clarify how confidentiality, anonymization, and data storage will be managed.

6. Discussion:

The discussion section contains repetition and includes findings from previous studies rather than focusing on the expected contribution of the protocol.

Recommendation:

- Focus on anticipated contributions.

- Avoid redundancy with the introduction.

Conclusion:

The manuscript addresses a relevant topic with an appropriate qualitative design. However, significant revisions are required to improve clarity, methodological transparency, and overall quality before it can be considered for indexing.

Is the study design appropriate for the research question?

Partly

Is the rationale for, and objectives of, the study clearly described?

Partly

Are sufficient details of the methods provided to allow replication by others?

Partly

Are the datasets clearly presented in a useable and accessible format?

Partly

Reviewer Expertise:

pharmacogy

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

F1000Res. 2026 Mar 12. doi: 10.5256/f1000research.193343.r461351

Reviewer response for version 1

Tri Yulianti 1

The research to be conducted is very interesting regarding medication adherence among elderly people in the Waterberg region. However, several things need to be considered to improve the clarity of the research to be conducted.

In the title section, to differentiate this article from published articles from research results, specific research methods can be included, such as protocols for qualitative or phenomenological research.

Abstract:

The last sentence in the introduction states that the study's findings can improve adherence rates, which seems inappropriate given that it is an observational study. The contribution that can be made from the results of this study can be conveyed; e.g., health workers can tailor services to the problems faced by elderly patients or develop interventions to improve medication adherence.

The objectives in the abstract can be adjusted to align with the manuscript, not only to explore medication adherence in the elderly but also to examine the experiences and perceptions of medication adherence among elderly patients.

In the methods section, the research design to be used can be explained. Information about the population to be studied, sample size, inclusion criteria, and data collection methods can be added to improve clarity for readers.

Article:

In the introduction section, the first and fifth paragraphs repeat information on existing research on medication adherence in Africa. Such repetition of information should be avoided. It would be better to present the results of previous research and its limitations, as well as information that has not yet been obtained regarding medication adherence among older adults in Africa, thereby highlighting the importance of this research. Then, the fourth and fifth paragraphs contain information that is more relevant to the general population. Since this is an article for geriatric patients, it could be made more specific to their conditions.

In the methods section, for inclusion criteria, note that this study focuses on medication adherence; therefore, patients must have been regularly using the medication for at least 3 months to ensure they are indeed those who use it. Also, for the types of chronic diseases studied, the diseases can be specified more precisely.

For the sample size information, it is necessary to explain when the data can reach saturation. Please state whether sampling techniques were used in this study, e.g., purposive sampling.

In the interview guide, it can be explained which domains or aspects will be studied with patients, e.g., medication knowledge, barriers and facilitators, patient beliefs, and medication-taking habits.

It is necessary to explain who will conduct the interviews and whether they are competent to do the interviews, because the depth of the data collected depends on the interviewers.

In the discussion section, the author discusses medication adherence in relation to various factors identified in previous studies, many of which are not entirely relevant. The author could have presented the expected results of the study and the future contributions to be made.

Is the study design appropriate for the research question?

Yes

Is the rationale for, and objectives of, the study clearly described?

Partly

Are sufficient details of the methods provided to allow replication by others?

Partly

Are the datasets clearly presented in a useable and accessible format?

Not applicable

Reviewer Expertise:

pharmacy practice-based studies, clinical pharmacy, and medication management.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

F1000Res. 2026 Feb 28. doi: 10.5256/f1000research.193343.r461352

Reviewer response for version 1

Mohammed Alfaqeeh 1

Comments to Authors

General Comments

This study protocol addresses an important and timely public health issue, medication adherence among elderly patients with chronic diseases in the Waterberg District, Limpopo Province. The topic is relevant given the growing burden of multimorbidity and population ageing in South Africa. The protocol is generally well structured, ethically approved, and proposes an appropriate qualitative phenomenological design; however, some areas require clarification to enhance methodological rigor and transparency. In particular, the authors should more clearly specify the phenomenological orientation, justify the sampling strategy, provide greater detail on the interview and translation procedures, and strengthen the description of thematic analysis and strategies to ensure trustworthiness. With moderate revision, this protocol has strong potential to contribute meaningful contextual insights into medication adherence among elderly patients in this setting.

----------------------------

Title

The title clearly identifies the topic (medication adherence), target population (elderly patients), and geographic context (Waterberg District, Limpopo Province), which helps readers immediately understand the scope of the study.

However, as this is a study protocol using a qualitative phenomenological approach, the title would benefit from explicitly indicating the study design. Including terms such as “a qualitative study protocol” or “a phenomenological study protocol” would improve methodological transparency and align with reporting standards for protocols, allowing readers and indexers to immediately distinguish this work from a completed empirical study. Additionally, the phrase “a selected hospital” is somewhat vague. If confidentiality is not required, consider specifying the type of facility (e.g., district hospital) to enhance contextual clarity. If anonymity must be maintained, a brief justification may be helpful within the manuscript.

Suggested revision: Medication Adherence Among Elderly Patients Receiving Healthcare Services in Waterberg District, Limpopo Province: A Qualitative Phenomenological Study Protocol.

----------------------------

Abstract

The abstract gives a clear overview of the topic and intended exploration of medication adherence among elderly patients.

  • It should explicitly state the study design (qualitative phenomenological study/protocol) to distinguish it from a completed study.

  • The methods description is too brief; consider adding:

  • study population (elderly ≥60 years with chronic disease),

  • study setting,

  • anticipated sample size (15–30 participants),

  • sampling approach and use of in-depth interviews.

  • The phrase suggesting the study will “improve adherence rate” may overstate the scope; reword to emphasize understanding experiences, barriers, and facilitators rather than implying impact.

----------------------------

Introduction

The introduction provides relevant background on medication adherence and the growing burden of chronic disease among the elderly globally and in South Africa.

  • Demographic statistics are detailed; however, they are presented sequentially. Consider synthesizing them to highlight the key message (ageing population → increased chronic disease burden → adherence challenges).

  • Some sections are overly broad (e.g., general discussion of noncommunicable diseases). These could be condensed to maintain a stronger focus on medication adherence in the elderly.

  • The local context (Waterberg District) is introduced, but the rationale for selecting this specific setting should be strengthened (e.g., service delivery challenges, rural characteristics, or lack of prior qualitative evidence).

  • The literature review lists studies but does not clearly identify the knowledge gap. Explicitly state what is not yet understood (e.g., lived experiences, contextual barriers, health-system influences).

  • Consider ending the introduction with a clear transition linking the identified gap directly to the study aim.

----------------------------

Objectives

The objectives are relevant to a qualitative inquiry and appropriately focus on exploring experiences and perceptions of medication adherence among elderly patients.

  • The objectives could be more aligned with phenomenological research by emphasizing understanding the lived experience of medication adherence rather than using general terms.

  • Consider adding a statement indicating the intention to identify barriers and facilitators influencing adherence, if this is part of the analytical focus described elsewhere in the protocol.

----------------------------

Methods

Study Design

The use of a qualitative phenomenological design is appropriate for exploring experiences and perceptions of medication adherence among elderly patients.

  • However, the protocol does not specify which phenomenological approach is being followed (e.g., descriptive vs. interpretive). Clarifying the philosophical orientation would strengthen methodological rigor.

  • Consider briefly explaining why phenomenology is the most suitable design for this research question, beyond stating that it allows in-depth understanding.

  • It would also be helpful to indicate whether the study follows any qualitative reporting framework (e.g., COREQ or SRQR) to enhance transparency and credibility.

Population and Eligibility Criteria

The target population (elderly patients aged ≥60 years with at least one chronic disease receiving healthcare services) is clearly defined. Inclusion and exclusion criteria are appropriate; excluding individuals with severe cognitive impairment is reasonable for interview-based research.

  • However, the sampling strategy is not specified. Clarify whether participants will be selected using purposive, convenience, or maximum variation sampling, and justify the choice.

  • Consider explaining how diversity will be ensured (e.g., gender, type of chronic disease, duration of treatment).

  • Since recruitment occurs at the outpatient department, discuss whether this may exclude more frail or home-bound elderly individuals and how this might influence transferability.

Sample Size

The proposed sample size of 15–30 participants, guided by data saturation, is generally appropriate for a phenomenological study.

  • However, the concept of data saturation should be briefly defined, including how the researcher will determine that saturation has been reached (e.g., no new themes emerging across consecutive interviews).

  • Clarify whether recruitment will stop strictly at saturation or within the predefined range (15–30 participants).

  • Consider justifying the proposed range by referencing qualitative methodological literature to strengthen rigor.

Interview Guide and Data Collection

The use of unstructured interviews with probing is appropriate for a phenomenological study exploring lived experiences.

  • However, stating that the guide includes only “two central questions” is vague. Consider briefly outlining the nature or domains of these questions (e.g., daily medication routines, challenges, support systems).

  • Clarify whether the interview guide will be pilot-tested and refined before full data collection.

  • The translation of the guide into Sepedi is appropriate; however, explain whether back-translation or validation will be performed to ensure conceptual equivalence.

  • Field notes are mentioned; specify how they will be integrated into the analysis.

  • Since the researcher may have previously provided care to participants, consider explaining how interviewer bias and power dynamics will be minimized.

Data Analysis

Comment to Authors

The use of thematic analysis is appropriate for identifying patterns in participants’ experiences and perceptions.

  • The protocol outlines general steps (transcription, familiarisation, coding, theme development), which is helpful; however, it should reference a specific analytical framework (e.g., Braun & Clarke’s approach) to enhance methodological transparency.

  • Clarify who will perform the coding and whether more than one researcher will be involved to improve dependability.

  • Describe how disagreements in coding or theme interpretation will be resolved.

  • Consider explaining strategies to ensure trustworthiness, such as credibility (member checking), dependability (audit trail), confirmability (reflexive notes), and transferability (thick description).

Ethical Considerations

Comment to Authors

Ethical approval from the University of Venda Research Ethics Committee is clearly stated, which strengthens the protocol’s ethical compliance.

  • The protocol mentions informed consent, confidentiality, and voluntary participation; however, consider briefly explaining:
    • how confidentiality will be maintained (e.g., anonymisation, secure data storage)
    • how audio recordings and transcripts will be protected
    • how participants will be identified using codes rather than names

  • It would also be useful to mention whether participants may withdraw their data after the interview if they choose to do so.

----------------------------

Discussion

  • Much of the content repeats barriers already cited in the introduction. Consider condensing this section to avoid redundancy.

  • Since this is a protocol, the discussion should focus more on:

  • the anticipated contribution of the study

  • how it will address the identified knowledge gap

  • and how findings may inform practice or policy in the local context

  • Avoid presenting literature findings in a way that appears to pre-empt or predict your study results.

  • If retained, this section could instead be reframed as “Expected Contribution” or integrated into the introduction.

Is the study design appropriate for the research question?

Yes

Is the rationale for, and objectives of, the study clearly described?

Partly

Are sufficient details of the methods provided to allow replication by others?

Partly

Are the datasets clearly presented in a useable and accessible format?

Not applicable

Reviewer Expertise:

Public health researcher trained in epidemiology and health economics, focusing on communicable and non-communicable diseases, vaccine policy, ageing populations, and evidence-based health decision-making. Experienced in systematic evidence synthesis, pharmacoeconomic modelling, and translating research findings into policy recommendations.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Data Availability Statement

    Data supporting this study will be made available upon request after the research is completed, ensuring adherence to ethical standards. Data will be available from the corresponding author thomphomavhungu4@gmail.com on reasonable request. Access will be granted to researchers who provide clear research purpose and methodology, agree to comply with the University of Venda’s data sharing policies and ethical approval.

    Underlying data

    No data is associated with this article.

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