Factors Influencing Medication Literacy in Young and Middle-Aged Patients with NYHA Class I–III Heart Failure After Percutaneous Coronary Intervention: A Qualitative Study

Abstract

Objective

To identify and understand the factors that influence medication literacy in young and middle-aged patients with NYHA class I–III heart failure following percutaneous coronary intervention (PCI).

Methods

From October to December 2024, 21 post-PCI patients with NYHA class I–III heart failure aged 18–65 were included in this study, using purposive sampling. Semi-structured interviews were conducted with them. Data were analyzed using directed content analysis for coding, categorization, and thematic extraction.

Results

Four primary themes encapsulating the barriers to medication literacy emerged: (1) Deficiencies in foundational drug knowledge, stemming from overly simplistic patient education and a clinical focus on instructional process over practical understanding; (2) Insufficient communication channels with healthcare providers and within families; (3) A lack of critical appraisal skills, evident in persistent cognitive biases and an overreliance on unvetted online health information; and (4) Poor medication management literacy, driven by challenges in adapting lifestyles, work and travel schedules, role transitions, and coping with treatment-related negative emotions.

Conclusion

Enhancing medication literacy in this patient population requires a multifaceted strategy. Healthcare teams should develop more nuanced, interactive education programs, establish robust communication and social support systems, actively address patients’ cognitive biases while improving their e-health literacy, and help patients integrate medication management seamlessly into their daily routines.

Introduction

Percutaneous coronary intervention (PCI) is a cornerstone procedure for coronary revascularization, effectively restoring blood flow in stenotic or occluded vessels and improving patients’ hemodynamic status.¹ Notably, the demographic profile of coronary artery disease is shifting, with a rising annual incidence among younger populations, thereby increasing the number of young and middle-aged individuals undergoing PCI.² While PCI addresses acute obstruction, it does not cure the underlying atherosclerosis. Consequently, long-term pharmacotherapy is imperative to prevent complications such as stent restenosis and sudden cardiac death, making post-PCI medication adherence a critical determinant of long-term outcomes.³

Medication literacy—the capacity to access, comprehend, communicate, evaluate, and calculate medication-related information to make appropriate decisions—is a key facilitator of medication adherence.^4,5 Compared to their elderly counterparts, young and middle-aged post-PCI patients often possess higher educational attainment and bear significant familial and occupational responsibilities, leading to greater expectations for a full recovery. Paradoxically, evidence suggests that medication literacy is frequently inadequate in this very group.^6,7 A clear understanding of the factors contributing to this deficit is therefore essential to design targeted interventions that can improve adherence and ensure medication safety.

Existing research on medication literacy relies heavily on quantitative methodologies. Few studies employ qualitative approaches to explore the lived experiences and perceptions of young and middle-aged PCI patients regarding their medication management. This qualitative study aims to address this gap by examining the motivations, challenges, and contextual factors that shape medication literacy in this population, thereby providing a foundational evidence base for developing effective, patient-centered intervention strategies.

Methods

Participants

We employed a descriptive qualitative study design to explore participants’ subjective experiences. This approach is appropriate for obtaining rich, straight descriptions of participants’ perspectives and understanding the factors that influence their medication literacy. A purposive sample of patients was recruited from the cardiology outpatient clinic and inpatient wards of a tertiary care hospital between October and December 2024. Eligible participants were aged 18–65 (aligning with WHO classifications), had undergone PCI, presented with NYHA class I–III heart failure, and provided informed consent for themselves and their families. Patients with NYHA class IV heart failure were excluded because their severe functional impairment and symptoms at rest may affect cognitive engagement and communication during in-depth interviews, potentially introducing confounding related to disease severity rather than medication literacy. The inclusion of NYHA class I–III patients ensured a relatively homogeneous cohort capable of providing rich, meaningful qualitative data. Patients were excluded if they had major psychiatric disorders, significant cognitive impairment, malignancy, or severe organ failure. Recruitment continued until thematic saturation was achieved, resulting in a final sample of 21 participants. Their demographic characteristics are summarized in Table 1.

Table 1.

Participant Demographics (n = 21)

NO.	Gender	Age (y)	Education Status	Occupation	Type of Financial Support for Medical Care
P1	Male	50	High school	Office worker	Medical insurance
P2	Male	53	Middle school	Worker	Medical insurance
P3	Male	37	Junior college	Delivery driver	Medical insurance
P4	Female	51	Middle school	Office worker	New Rural Cooperative Medical Scheme
P5	Male	43	Bachelor’s degree	Teacher	Medical insurance
P6	Male	46	Junior college	Office worker	Medical insurance
P7	Male	45	Junior college	Office worker	Medical insurance
P8	Male	33	Bachelor’s degree	Office worker	Medical insurance
P9	Female	48	Junior college	Freelance	Medical insurance
P10	Male	39	Bachelor’s degree	Self-employed	Medical insurance
P11	Male	47	Bachelor’s degree	Self-employed	Medical insurance
P12	Male	35	Bachelor’s degree	Civil servant	Medical insurance
P13	Male	38	Junior college	Freelance	Medical insurance
P14	Male	54	Junior college	Office worker	Medical insurance
P15	Female	58	Middle school	None	New Rural Cooperative Medical Scheme
P16	Male	45	High school	Freelance	Medical insurance
P17	Male	30	High school	Self-employed	Medical insurance
P18	Male	62	Junior college	Office worker	Medical insurance
P19	Male	44	High school	Office worker	Medical insurance
P20	Male	55	High school	Office worker	New Rural Cooperative Medical Scheme
P21	Female	37	High school	Self-employed	Medical insurance

Data Collection

Data were collected through individual, face-to-face, semi-structured interviews conducted in a private demonstration classroom. Each interview, lasting approximately 30 minutes, was performed by a trained researcher. Prior to the interview, the study’s purpose, procedures, and confidentiality measures were explained in detail, and written informed consent was obtained. With participants’ permission, all interviews were audio-recorded to ensure accuracy and completeness.

The interview guide was developed based on a conceptual model of medication literacy encompassing theoretical, communicative, critical, and management domains.⁸ An initial guide was drafted following a literature review and refined through team discussions and pilot interviews with two post-PCI patients. The final interview questions included:

(1) Could you describe the medications you are currently taking and what you understand about their purpose?

(2) How do you organize and remember to take your medications each day? Do you feel this routine works well?

(3) What difficulties, if any, do you face in taking your medications as prescribed? Who or what do you turn to for help with these issues?

(4) Where do you typically look for information about your medicines or condition? How do you judge whether that information is trustworthy?

(5) In your view, what could be improved about how healthcare staff educate patients about medications? What specific knowledge do you feel you are missing?

Data Analysis

All interviews were conducted and audio-recorded in Mandarin Chinese, the native language of all participants and researchers, and each recording was transcribed verbatim in Mandarin within 24 hours of the interview. Two researchers independently analyzed the Mandarin transcripts using directed content analysis,⁹ guided by the conceptual model of medication literacy that informed the interview guide—an approach that allowed us to start with predetermined domains while remaining open to inductive identification of subthemes and novel insights from the data. The analysis process involved: (1) repeated reading of all transcripts to achieve immersion and gain a holistic understanding of the data; (2) open coding of significant statements and meaning units directly related to medication literacy; (3) grouping codes into subcategories based on similarities and differences; and (4) abstracting these subcategories into overarching themes. The two researchers coded the data in Mandarin, after which the Mandarin transcripts and the identified codes and themes were translated into English by two additional independent bilingual researchers—native Chinese speakers with professional English proficiency—who prioritized conceptual equivalence (conveying meaning and intent) over literal word-for-word translation to preserve the richness and accuracy of participants’ narratives. Any disagreements in translation or coding were resolved through discussion among the four researchers until consensus was reached. To enhance trustworthiness, a summary of the identified themes was shared with a subset of participants for member checking and validation. This systematic approach ensured that the thematic findings remained grounded in the participants’ original expressions.

Results

The four primary themes identified in this study correspond to the four domains of the medication literacy conceptual model (theoretical, communicative, critical, and management) that guided the interview guide and the directed content analysis. Within each theme, subthemes were derived inductively from participant narratives.

Theme 1: Deficiencies in Foundational Drug Knowledge

Simplistic Health Education Content

Participants reported that medication education from clinicians was often generic, covering only basic drug names, actions, and common side effects. While perhaps sufficient for some, this depth failed to satisfy younger patients who desired a more mechanistic understanding and long-term perspective. One participant (P4) expressed:

The discharge instructions repeated the basics—what the pills are for and when to take them. I can find that online. What I really want to know is when I might be able to reduce the dose, or how my heart medications interact with the ones I take for my blood pressure.

Process-Oriented Over Practical Education

Education was frequently delivered as a one-way, checklist-driven activity rather than an interactive dialogue aimed at ensuring comprehension. The focus appeared to be on the act of informing rather than on the outcome of understanding. As one participant (P9) noted:

The nurse was going through the medication list, but I was checking my phone. I only really caught the part about watching for bleeding with the blood thinners.

Theme 2: Insufficient Communication Channels

With Healthcare Providers

A significant barrier was the perceived inaccessibility of healthcare providers for follow-up questions. Patients cited time constraints during clinic visits, the use of intimidating medical jargon, and a personal reluctance to bother busy staff as key reasons. This often led them to seek answers elsewhere. The doctors are in a hurry during rounds, and they use terms I do not understand, shared P14. Another (P18) added, “I don’t want to seem difficult or needy by asking too many questions”.

Within the Family System

Family support for medication management was often less active than expected. Families sometimes assumed that younger patients were capable of self-management, reducing reminders and supervision. Concurrent life pressures also limited family communication about health. “My family thinks that since I’m young, I should handle my own medications. They don’t really ask about it” said P21. Another participant (P6) internalized this:

Talking about my worries just adds to their burden, so I keep it to myself.

Theme 3: Lack of Critical Appraisal Skills

Persistent Cognitive Biases

Several patients held beliefs that directly conflicted with prescribed therapy, such as equating the absence of symptoms with being “cured”, or overestimating the risks of long-term medication. These biases prompted unsupervised changes. Participant P15 stated:

I feel perfectly fine now. Since they said blood thinners can cause bleeding, I’ll just finish this batch and then stop.

Overreliance on Unvetted Online Information

While the internet was a primary source of health information, patients struggled to assess its credibility. The sheer volume of conflicting advice online could be paralyzing or misleading. “I look everything up on short video platforms. It’s convenient, but you get ten different opinions”, remarked P10. Some even developed a misplaced trust in digital sources, with P19 observing, “Some of the ‘online doctors’ explain things more clearly than my own cardiologist did”.

Theme 4: Poor Medication Management Literacy

Challenges of Habit Integration and Lifestyle

Integrating a strict medication regimen into an established, often irregular lifestyle was a common hurdle. Some patients actively resisted the identity of a “chronic patient”. P3 described a typical pattern:

My sleep schedule is erratic, so my ‘morning’ dose often gets taken at noon.

P8 expressed resistance:

Committing to a pill schedule for life feels like surrendering my normal life.

Disruption from Work and Social Demands

Professional obligations and social activities frequently disrupted routines. Business dinners, travel, and uncertainty about drug-interactions (especially with alcohol) led to missed doses. “I often have client dinners and don’t carry my pills with me”, explained P7. P11 avoided medication when drinking due to uncertainty, while P20 noted the problem of travel:

I pack for a three-day trip, but it extends to five, and I run out.

Difficult Role Transition and Negative Emotions

The shift from a primary identity as a parent, spouse, or professional to that of a “cardiac patient” was psychologically challenging, creating conflict and sometimes denial. “I’m pulled in so many directions—work, kids, aging parents. Being a perfect patient isn’t always the priority”, said P4. Additionally, the complexity and perceived burden of polypharmacy fostered frustration and anxiety. “It’s just so tedious. Different pills at different times, forever”, expressed P13 with evident weariness.

Discussion

The factors shaping medication literacy in young and middle-aged patients after PCI are complex and deeply interwoven with their life contexts. Our findings suggest that the deficit is not merely one of information but involves interconnected gaps in dialogue, discernment, and daily implementation. This underscores the limitation of interventions focused solely on knowledge transfer.

Current patient education paradigms, often standardized and didactic, fail to engage this population’s capacity for deeper understanding.¹⁰ These patients seek not just instructions, but rationale and evidence—a need unmet by brief discharge counselling.¹¹ Evolving from a monologue to a collaborative dialogue is critical. This requires educational content that is layered and adaptable, and a process that actively checks for comprehension and addresses individualized concerns.¹² Frameworks that promote “shared understanding” through iterative conversation may prove more effective than static information delivery.¹³

Communication barriers with providers, characterized by perceived time pressures and hierarchical dynamics, often divert patients to the unregulated digital space. Simultaneously, families tended to underestimate the need for active support, creating a dual void in patients’ support networks. Our findings specifically highlighted that participants perceived significant obstacles to accessing providers for follow-up questions (Theme 2), citing time constraints during clinic visits and reluctance to “bother” busy staff as key deterrents. To address this specific barrier, system-level solutions may be beneficial, such as establishing more accessible consultation pathways (eg, dedicated clinical pharmacist follow-up or secure messaging systems). At the same time, actively coaching families on how to provide supportive,^14,15 non-patronizing engagement could strengthen patients’ support networks from the family side.¹⁶ These strategies are proposed as potential responses to the communication gaps explicitly voiced by our participants, rather than as universally applicable interventions.

Cognitive biases, such as discounting future risk when feeling well, are potent drivers of non-adherence. When combined with low e-health literacy, they make patients vulnerable to misinformation.¹⁷ Clinicians must proactively create space to uncover and gently challenge these beliefs during clinical encounters, connecting medication purposes directly to patients’ life goals. Furthermore, guiding patients toward credible, patient-oriented digital resources—rather than merely condemning internet use—can build their critical appraisal skills and empower safer information-seeking.^18,19

Finally, medication literacy must translate into sustainable practice. Knowledge fails when it clashes with reality: busy schedules, travel, and emotional fatigue. Effective support includes co-developing practical strategies like habit-stacking (linking medication to a daily routine), leveraging technology (smart pillboxes, contextual phone reminders), and planning for contingencies like travel.²⁰ Acknowledging and normalizing the frustration associated with chronic medication is itself a therapeutic intervention that can mitigate its negative impact on adherence.²¹

Limitations

This study was conducted at a single tertiary-care center, and the sample size, while sufficient for qualitative inquiry, may not capture the full spectrum of experiences across different healthcare settings. The perspectives of healthcare providers were not included, which represents an important avenue for future research. Additionally, our inclusion criteria restricted participation to patients with NYHA class I–III heart failure, which limits the generalizability of our findings to the broader post-PCI population, including those with more severe heart failure (NYHA class IV). Future research should explore whether similar factors influence medication literacy across the full spectrum of post-PCI patients.

Conclusion

This study identifies a multifaceted constellation of factors—encompassing knowledge, communication, critical thinking, and practical management—that influence medication literacy in young and middle-aged post-PCI patients. Moving forward, effective support requires an integrated approach: providing deeper, dialogic education; establishing responsive and accessible communication channels; guiding the critical evaluation of health information; and embedding medication-taking into daily life through personalized, practical tools. Future research should focus on developing and evaluating multidimensional interventions based on this holistic understanding. It should be noted, however, that our findings are derived from a specific population of young and middle-aged post-PCI patients with NYHA class I–III heart failure. Caution is warranted when generalizing these results to the broader post-PCI population, including those with NYHA class IV heart failure. Future studies with more diverse patient populations are needed to validate and extend our findings”.

Funding Statement

This study was supported by a grant from Nursing Special Project of Taizhou People’s Hospital (Number Grant: HLZD202404).

Data Sharing Statement

The datasets generated and analysed during the current study are not publicly available but are available from the corresponding author (Lu Chen) on reasonable request.

Ethics Approval and Consent to Participate

This study was reviewed and approved by the Ethics Committee of the Affiliated Taizhou People’s Hospital of Nanjing Medical University (Approval No. KY2024-076-01) and conducted following the declaration of Helsinki. Written informed consent was obtained from each participant.

Consent for Publication

Consent for publication was obtained from every individual whose data are included in this manuscript.

Disclosure

The authors declare no competing interests.