Contextual factors influencing medication management by rural informal caregivers of older adults

Abstract

Background:

Managing medications is an important part of the rural informal caregiver’s role in the community setting, and the context within which care is provided plays an important role in shaping the work they perform. However, little is known about the intra- and interpersonal factors that impact the rural caregiver’s involvement in and performance of medication management.

Objectives:

To identify contextual factors influencing medication management by rural informal caregivers of older adults.

Methods:

Four separate focus groups with rural caregivers of older adults were conducted with 5 to 9 caregivers per group. Participants were asked to describe the medication management activities performed and problems they encountered while providing assistance. Focus groups were recorded, transcribed verbatim, and analyzed for themes using an inductive approach.

Results:

Care recipient independence, or their ability and preference to perform medication-related activities without supervision, was a key factor driving the caregiver’s involvement in medication management and how it was performed. Many caregivers used a team-based approach to medication management that supported the care recipient’s independence. Care recipient health and function was a driver behind the need for caregiving, and declines in physical and mental health led to changes in how medication management was carried out over time. Caregiver location also impacted the ways in which medication management was performed by caregivers.

Conclusions:

Interventions and pharmacy services to support medication management by rural informal caregivers should be designed in a way that preserves and promotes the care recipient’s independence, and should be tailored to the context within which caregiving is performed.

Introduction

Informal caregivers, or unpaid family and friends, play a vital role in providing care for older adults in the United States. An estimated 40 million people serve as informal caregivers to an adult with limitations in daily activities at some point during the year.¹ The estimated economic value of activities forgone as a result of providing this care, such as lost income due to reduced work hours to accommodate caregiving, is reported to be as high as $522 billion annually, or about $1,500 for every person in the United States.^1,2 Caregiver burden has also increased over time due to population aging, an increased number of individuals living with chronic disease, and a lack of formal support for informal caregivers.³

Managing medications is an important part of the informal caregiver’s role in the community setting.^4–7 It is the most common task reported by informal caregivers that perform medical tasks, with over half administering 5 or more prescription medications a day.⁴ They commonly perform a variety of medication-related tasks, including direct activities requiring physical handling of medications such as obtaining medications, preparing pill boxes, and assisting with medication administration, and indirect activities requiring more of a cognitive effort such as organizing and tracking medications, gathering information, and making treatment decisions.⁶ Caregivers also contribute to the health of the care recipient by promoting adherence to medications, ensuring medication safety, and reducing the likelihood of adverse drug events.^8,9

Several studies suggest that the context within which caregiving is provided plays an important role in shaping the general activities performed by informal caregivers. Care recipient characteristics such as age, physical health, mental health including cognitive limitations or dementia, and level of independence can impact the complexity of the care provided and the need for more intensive caregiving.^8,10,11 Similarly, caregiver characteristics such as age, physical and mental health, health literacy, and perceived burden or stress can impact the caregiver’s ability to assist the care recipient.^10,12–14 In addition, characteristics of the care recipient-caregiver dyad can also impact the care that is provided. For example, the caregiver’s approach to caregiving or care philosophy can also impact this role, encompassing factors such as partnering to manage medications, beliefs or attitudes about medications, independence, and autonomy or control.^8,15

However, little is known about which contextual factors have a meaningful impact on the caregiver’s involvement in medication management and how this activity is carried out. One study found that the caregiver’s age, cognitive ability, and depressive symptoms were important factors to consider when discussing medication management with caregivers of patients with memory loss.¹⁰ A secondary analysis of survey data by Noureldin and Plake⁵ found that different factors were related to the performance of different medication management activities. For example, factors associated with caregivers ordering medications included gender, higher involvement in instrumental activities of daily living, and care recipient age, education, race, and dementia status; in contrast, caregiver living arrangement and involvement in medically related activities were associated with keeping track of medications.⁵ In addition, although approximately 30% of informal caregivers and their older adult care recipients live in rural areas,¹¹ it is unknown how living in a rural area impacts the ways in which medications are managed by caregivers.

It is unclear which of these factors are most relevant from the caregiver’s perspective and how they impact the caregiver’s performance of medication management activities. In addition, health care providers and researchers lack a concrete understanding of how contextual factors influence medication management by informal caregivers, which is critical in order to tailor support services to best meet the needs of each caregiving situation and is particularly important in rural areas. Therefore, the objective of this manuscript was to identify factors influencing medication management by rural informal caregivers, and to describe how they influence the performance of these activities.

Design and Methods

Sample

Informal caregivers were recruited to participate in one of four 90-minute focus group discussions. The purposive sample consisted of caregivers in rural areas that provided assistance with medications to an older adult friend or relative age 65 or older. Rural caregivers were selected in order to identify issues that may be specific to medication management performed by rural caregivers. There were no requirements with regard to caregiver health and function or the level, duration, or extent of caregiver involvement with medications, which was done deliberately in order to fully explore the range of caregiver involvement in medication-related activities. Caregivers were recruited from one rural Wisconsin county using a multimodal approach. Individuals that were currently or had previously attended a caregiving class, support group, or caregiver meeting offered through the county’s aging department were mailed a recruitment letter by the aging department informing them of the opportunity to participate in a focus group. A recruitment advertisement was placed in the county’s monthly aging newsletter, and in-person recruitment was performed at the county’s annual caregiver conference. Finally, key informants in the county’s aging department assisted with identification and personal referral for potentially eligible caregivers.

Interested caregivers were administered a screening questionnaire to determine whether they qualified to participate and to assist with focus group assignment. Eligible caregivers were those currently providing unpaid assistance to an older adult age 65 or older with their medications. Caregivers providing assistance to an adult child with or without disabilities were excluded due to the differing nature of this type of care. At the end of the focus group, an exit questionnaire was administered, which contained demographic information about the caregiver and their care recipient. Participants were paid $50 for their participation and complementary respite care was available to facilitate caregiver participation in the focus groups. This project was reviewed and granted exempt status by the Health Sciences Minimal Risk institutional review board at the University of Wisconsin-Madison.

Study Design

Focus groups were chosen as the data collection method for this research in order to bring informal caregivers together to discuss medication management in depth and to use the interaction between group participants to generate detailed insights on the issues faced when managing medications for their care recipient from the caregiver’s perspective. The focus groups were moderated by an experienced focus group facilitator from the University of Wisconsin Survey Center and attended by the principal investigator (K.A. Look). Four focus groups were held in three locations in different parts of the county, and were conducted during November and December of 2015.

A questioning route¹⁶ was developed and administered at all focus groups using the Patient Work System model as a guiding framework.¹⁷ This human factors model depicts how the interactions between a person(s), the tasks they perform, the tools they use, and the context in which work is performed, shapes how tasks are performed as well as the associated patient outcomes. Each group was first asked to describe the kinds of activities or tasks that they perform to assist someone with their medications. Next, they were asked to describe the ways in which they help someone take their medications as directed and the methods or tools that they use in the process. Participants were also asked how they manage changes in medications or health. Group activities included brainstorming a list of problems the caregivers had encountered while assisting their care recipients with medications, and discussing actual or potential solutions to these problems. Lastly, caregivers were asked to reflect on how the assistance they provide with medications is affected by where they live. This paper focuses on how contextual factors impacted how the caregivers managed medications for the care recipient.

Analysis

All four focus groups were digitally recorded with the permission of the participants. Verbatim transcripts of the audio recordings were prepared to facilitate thematic analysis, and all interview transcripts were checked against audio recordings for accuracy. Data analysis proceeded in several steps, including familiarizing with data, generating initial codes, identifying recurrent patterns, defining and naming themes, and reviewing themes.¹⁸ Two researchers read the transcripts independently several times to familiarize themselves with the entire transcript. The researchers then independently coded the transcripts using an inductive approach.¹⁹ Each participant response was given a label such as “caregiver may have physically difficult time administering medications” or “patient trusts caregiver to care for them”. Following independent coding, the researchers met and compared codes. Any discrepancies in codes were discussed until agreement was reached. Codes that were similar or related were grouped together to form themes and subthemes using an iterative process, and representative quotes for each theme were identified from the transcripts. Coding was performed using the data analysis software NVivo 11.

Results

A total of 29 informal caregivers participated in the study (Table 1). Caregiver age ranged from 42 to 85, while care recipient age ranged from 65 to 106. The length of time the caregiver had assisted the care recipient with their medications ranged from 2 months to 12 years. The vast majority of the caregivers were female (83%), and assisted a spouse (48%), or parent or parent-in-law (38%). About 1/3 of the caregivers had received some kind of training on how to assist someone with medications, which included informal training (e.g., medication administration directions from a health care provider), or formal training most often in the form of formal education as a health care worker (e.g., nurse, nurse’s aide, military corpsman, etc.). About 1/3 of the caregivers assisted an individual with dementia. The majority (79%) of caregivers managed 5 or more medications, while 31% managed 10 or more. About half of the care recipients lived in the same household as their caregiver, while the majority of those that lived separately lived less than 20 minutes away.

Table 1:

Sample Characteristics (N = 29)

Variable	Mean (SD)
Caregiver characteristics
Age (years)	67.1 (11.7)
Gender (%)
Male	17
Female	83
Length providing care (years)	4.8 (3.6)
Relationship to care recipient (%)
Spouse	48
Child or child-in-law	38
Other friend or relative	14
Medication assistance training (%)
Yes	38
No	62
Care recipient characteristics
Age (years)	83.4 (8.9)
Dementia diagnosis (%)
Yes	34
No	66
Number of medications taken (%)
1–4	21
5–9	48
≥10	31
Living distance from caregiver (%)
In same household	52
< 20 minutes away	45
>20 minutes away	3

Thematic analysis identified three main themes, with care recipient independence as a key factor driving the caregiver’s involvement in medication management and how medication management was performed (Table 2). Two related factors that also influenced the extent of caregiver involvement in medication management or how this activity was carried out were care recipient health and functioning and caregiver location. Representative quotes from the transcripts were identified for each factor, and are presented along with the caregiver’s gender and the relationship of the care recipient to the caregiver (e.g., parent indicates the caregiver assists a parent with their medications).

Table 2:

Contextual Factors Influencing Caregiver Medication Management

Care Recipient Independence

• More independent care recipients required less caregiver assistance with medications  • Caregivers stressed importance of promoting care recipient independence and autonomy

Care Recipient Health and Function

Health and function as a driver of caregiver involvement in medication management

• Change in care recipient physical or mental health often the reason caregivers began providing assistance with medications  • Changes may be gradual or due to sudden health events  • Influences extent of caregiver involvement in medication management

Health and function contributing to medication-related problems

• Physical limitations led to difficulties taking or administering medications  • Mental limitations (e.g., dementia) frequently contributed to problems remembering to take medications and taking wrong medications

Care recipient independence and health and function

• Discussions of care recipient independence frequently accompanied discussions of physical and mental health and function  • Extent of caregiver involvement in medication management increased over time as health and function declined

Caregiver Location

Caregiver living situation

• Caregivers living with care recipient typically handled all aspects of managing medications; care recipients were passive participants  • Caregivers living separately from care recipient had more variability in extent of involvement with medications; caregivers developed ways to support care recipient taking medications on their own

Caregiving in a rural area

• Lack of caregiving assistance and support  • Lack of pharmacy access due to pharmacy closures, resulting in long travel to obtain medications  • Difficulty obtaining medications on evenings and weekends when pharmacies were closed  • Caregivers viewed these issues as inconveniences that were normal aspects of living in a rural area

Care Recipient Independence

The care recipient’s level of independence, or their ability to adequately perform medication-related activities without supervision, was identified by the caregivers as one of the most important factors shaping the activities they performed. Care recipients who were more independent were able to perform a larger number of medication-related activities on their own, requiring less direct involvement by the caregivers. These individuals were more likely to organize their own medications and take them without caregiver supervision, which reduced the burden on caregivers who were then responsible for only a subset of medication-related activities. These activities were often those that were more complex for an older adult to perform on their own. For example, one caregiver reported that their care recipient was able to take oral medications independently, but required assistance with the administration of eye drops and insulin injections.

Many caregivers stressed the importance of respecting the care recipient’s independence and autonomy whenever possible. They reported structuring their care in ways that preserved or promoted independence, such as using a team-based approach to medication management that involved both the caregiver and the care recipient. Others reported discussing medications with the care recipient and involving them in decisions related to the initiation, discontinuation, or change in a medication.

2003: He wants to be independent. He doesn’t like me telling him what to do. I mean, even just going with him to the doctor was something that I just started, um, and so he’s pretty used to that now. But, um, there’s another medication that he has been prescribed. It’s not totally necessary and he’s not so sure that he wants to take it. And I haven’t made him— I haven’t said, “OK, we’re putting it in your boxes this time.” I’m just going to keep talking to him about it. (Female, Spouse)

However, caregivers experienced resistance to their help in situations where the care recipient felt their independence or autonomy was being unfairly limited. This often resulted in a refusal to take medications as prescribed or resistance to the ways in which the caregiver organized medications. Some caregivers struggled to find ways to structure how they provided care while still promoting the care recipient’s independence and treating them with respect.

1004: He’s busy doing things for her, maybe getting her breakfast and different things like that and she’s saying, “Did you take your medicine? Did you take your medicine?” So, he gets a little flustered sometimes, you know. …. It isn’t that he refuses the medicine, it’s his— His frame of mind is taking care of her in a respectful way and being the head of the household. (Male, Sibling)

Care Recipient Health and Function

The care recipient’s health and function was one of the primary drivers behind the need for caregiving, and also influenced the nature and extent of the caregiver’s involvement in medication management activities.

Health and function as a driver of caregiver involvement in medication management

The caregivers often referred to a change in the physical or mental health of the care recipient as the primary reason they began providing assistance with medications. In some cases, the change was due to a sudden event such as a stroke, injury, surgery, or hospitalization; in others, it was due to the gradual deterioration of an existing condition such as worsening vision or dementia.

3007: I’ve always assisted my mom for the last three, four years, but now I have to assist my dad. But before I never assisted him. He broke his back three, four years ago and that’s when it started. (Female, Parent) 3001: When my mother came out of the hospital with the new medications, she was uh, very willing to let me set them up and so we have this role reversal now. She calls me her mother and sometimes I feel like she is my child. (Female, Parent)

The intensity of caregiver involvement varied widely based on the care recipient’s physical and mental health. Some caregivers had minimal involvement with medications, being involved in only one activity such as filling a pill box or checking to see if medications were being taken. Often this type of minimal monitoring occurred in situations where the care recipient had few chronic health conditions and few or no memory problems. Other caregivers were heavily involved in all aspects of medication management, including activities such as obtaining medications, filling pill boxes, administering medications, coordinating care with providers, and monitoring the patient for side effects. This level of involvement was more common in complex caregiving situations where the care recipient had limited health and function, such as a number of chronic health conditions, advanced dementia, or a complicated medication regimen involving a large number of medications or taking medications multiple times throughout the day.

2003: Well, that’s why I have started helping my husband. He had a TIA [transient ischemic attack] at the beginning of last year... And he was taking medications, but when that happened we went into the major kinds of medications that he had to start taking...and that’s when I started going to the doctor with him and then making sure that he took his medication regularly, because he could have, but there were times when he didn’t. (Female, Spouse)

Health and function contributing to medication-related problems

The care recipient’s health and function also contributed to medication-related problems. At times, these problems were due to physical limitations such as vision problems, difficulty swallowing or injecting medications, or manual dexterity problems such as dropping pills. However, medication-related problems were particularly common among individuals with memory problems. Caregivers reported that their care recipients commonly forgot to take their medications or weren’t taking their medications as prescribed. They also referred to situations where their care recipient mixed up their medications and took the wrong drug, took too much or too little of a medication, took a medication at the wrong time, or took someone else’s medications. These types of problems were also seen in situations where the care recipient had no diagnosed memory limitations.

4002: Well, she was on...a small pill. It’s hard to get. Sometimes she gets it out herself and she drops it on the floor. (Male, Spouse)

2009: Well, like, if I set out days and nights and then I set out some for myself, how confused they get if they saw them all three together. He wouldn’t know which ones were his, because he don’t pay attention. Because his, I put them in a separate-looking container so he should know that that’s nights and not days… And he still would take all three of them. (Female, Spouse)

Care recipient independence and health and function

In many instances, discussions of the care recipient’s level of independence frequently accompanied discussions of their physical and mental health and function, such that individuals with fewer limitations were described by the caregivers as being more independent and require less caregiver involvement with medications. In contrast, care recipients with significant physical or mental limitations, such as limited manual dexterity or even minor cognitive impairment, often required direct caregiver involvement in most medication-related activities. As a result, caregivers modified how they organized and performed their activities based on the health needs of the care recipient, and adapted their behavior to meet the changing needs of the care recipient over time.

2008: In [city], I took care of a lady. She was in her own home, but the pharmacy set up hers for a whole month in a bubble pack, and she was pretty reliable still to take them, because she would see the morning, noon, and that. But personally, in my life, my husband’s still pretty independent like yours, so I just kind of remind him at night. But I also administer the eye drops and the ear drops or if there’s anything like that, I do that. And I do look after the side effects too. (Female, Spouse)

The caregivers also discussed how their involvement in medication management changed over time as the care recipient’s independence declined due to changes in their health and function. The caregivers viewed themselves as playing a relatively minor supportive role when the care recipient was still able to manage medications on their own, performing limited tasks such as reminding the care recipient to take their medications as prescribed. As the care recipient’s health and function declined and they were no longer able to manage medications on their own, the caregivers gradually took on greater roles with medications. This usually took the form of ordering and organizing medications, while still allowing the care recipient to take the medications on their own. As the care recipient’s health and function further declined, the caregivers reported taking on additional activities until they became solely responsible for all medication-related activities, including the administration of medications. However, as mentioned previously the caregivers stressed the importance of preserving or promoting the care recipient’s independence and autonomy throughout this process.

2004: And it has kind of evolved over time. I was thinking at first I could set out two at a time, but he’d take both them. And, uh, then I—for a time he could get his own out of the pillbox, but then he would take morning and evening. And if my pillbox was sitting near he’d take mine too! (Female, Spouse)

Caregiver Location

Another important factor shaping the caregiver’s involvement in medication-related activities and how they were performed was their location or living situation; that is, whether the care recipient lived with or separately from the caregiver. Caregivers that lived with the care recipient typically handled all aspects of managing medications, from ordering through administration, regardless of the health and function of the care recipient. Although there was some variability, in many of these situations the care recipient became a passive participant who took whatever medications were given to them by the caregiver. However, caregivers reported that these care recipients were also less likely to know what medications they were taking or what they were for.

In contrast, there was much more variability in the caregiver’s level of involvement in medication management when the caregiver reported living separately from the care recipient. In some situations, the caregiver remained heavily involved in medication-related activities, such as organizing and administering medications. In other situations, the caregiver had minimal involvement, acting primarily to remind or to check if the care recipient took their medications on their own. As a result, the care recipient only helped with a subset of medication-related activities. For example, the caregiver might be responsible for ordering and organizing the medications, while the care recipient was responsible for taking the medications on their own.

2005: I have to keep track of how many pills are actually in that bottle, because she’s still in her apartment, independent and she does set out her own pills. But I have to keep track of how fast are we using this up, like her eye drops and things, you know, running out way too soon. (Female, Parent)

The caregiver’s location had an important impact on how caregivers structured their medication management and the tools and strategies they used to support those medication-related activities. Caregivers living with the care recipient adopted tools and strategies to support their own efforts, rather than those of the care recipient. For example, pill boxes were primarily used by these caregivers as an organizational tool to arrange the care recipient’s medications.

The caregivers also developed paper or electronic medication lists to help them with medication organization. Although they occasionally needed to develop ways to remind the care recipient to take their medications, they often simply handed the medications directly to the care recipient for immediate use.

2002: Well, I give it to him, because he can’t, uh, make decisions at all. So I have a box and, you know, through the week I fill it and just hand it to him when he’s ready, when he’s eating breakfast. (Female, Spouse)

3002: I keep track of what she takes. And I have to, uh, always make sure it’s ordered on time. But I try to check regularly to make sure she takes them, because she doesn’t take them if I don’t keep reminding her. And then after I do remind her, I still have to check that she took them, because she sometimes has them in her hand and lays them down on the cupboard, or just doesn’t— Her mind goes someplace else, too, just like mine does, only it’s a little worse. (Male, Spouse)

In contrast, caregivers living separately from the care recipient needed to develop ways to support the medication-related activities being performed by the care recipient. These caregivers developed numerous ways to remind the care recipient to take their medications, such as the use of verbal reminders, written or sticky reminder notes, and alarm clocks. Pill boxes were used as an adherence aid for the care recipient, and as a way for the caregiver to identify when medications were forgotten or not taken. Other strategies used to help the care recipient differentiate which medications to take at the proper time included the use of a calendar or checklist, and making modifications to their pill box by highlighting, color-coding, or writing on it. However, the usefulness of these tools and strategies varied depending on the care recipient’s level of independence.

3006: I’ve got the weekly pill reminders that have got four slots, and so, I tape just across the date the meals that they don’t get pills on. Those are just taped shut. So you don’t even have to worry about it. And then, when I fill it, I put a big sticky in bright fluorescent color usually that says, “Start Sunday, November, da-da-da.” (Female, Parent)

3005: When my mother came home from the hospital...my sister and I made a checklist. You know, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday. 7 o’clock, you do this. 8 o’clock, you do this. 9 o’clock, you do this. You know, we even had “Rest.” You know, “Eat lunch.” “Eat breakfast.” ...And then when she did it, she checked it off. (Female, Parent)

Caregiving in a Rural Area

Several factors related to living in a rural area were identified during the focus groups. A lack of caregiving assistance and support was mentioned as a common concern by the caregivers, as they were often the only person in the area that were willing and able to assist the care recipient with their medications. Several caregivers reported a lack of pharmacy access due to recent pharmacy closures in the county, which required them to travel long distances in order to obtain medications. Additionally, they also reported difficulties obtaining medications during times when pharmacies were closed such as on evenings and weekends. On the other hand, other caregivers reported easy access to pharmacies and had no difficulty obtaining medications, with several using mail order pharmacies to obtain medications. Overall, the caregivers viewed these issues as inconveniences that were normal aspects of living in a rural area, and that medication-related problems would occur regardless of where someone lived.

Discussion

The care recipient’s level of independence was one of the most important factors influencing the extent of caregiver involvement in and performance of medication-related activities, such that care recipients who were more independent required less direct caregiver involvement in medication management. Care recipient independence is an important factor impacting the complexity of care provided by caregivers and shaping the activities performed by the caregiver and care recipient, and has been found to be related to medication non-adherence in patients with dementia.⁸ Declining care recipient independence and functional capacity have also been found to increase care recipient reliance upon the caregiver for assistance with instrumental activities of daily living, which includes activities such as medication management.²¹ It is noteworthy that the caregivers in this study experienced resistance to their help in situations where the care recipient felt their independence was being infringed upon, and thus they stressed the importance of respecting or promoting the care recipient’s independence and autonomy whenever possible. Broadly speaking, promoting independence may preserve the dignity and autonomy of the older adult care recipient²⁰ while also reducing dependency on caregivers, which can contribute to reduced caregiver burden.³

The care recipient’s health and function was another factor impacting caregiver involvement in medication management. Declining care recipient health and function was commonly reported as one of the primary reasons caregivers first became involved in medication management, and caregiver involvement in and performance of medication management changed over time as the care recipient’s health and function declined. Although dementia is commonly identified as a disease contributing to medication-related problems and requiring caregiver involvement in medication management,^{5,8,10,11,22,23} little research has been conducted specifically on caregiver involvement in medication management for other medical conditions or in the context of managing multiple chronic diseases. A recent study by Noureldin and Plake⁵ found that dementia and lung disease were the only medical conditions significantly associated with more intensive caregiver involvement in medication management activities. However, the authors noted that care recipients with lung disease were more likely to have other co-morbid conditions, and that an increasing number of health conditions were associated with increased likelihood of caregiver involvement.⁵ In addition, the ability to recognize and interpret common symptoms or health changes has been identified as an important medication management skill for informal caregivers of hospice patients,²⁴ and other research has found that the number of medications and the number of changes in medications can contribute to medication non-adherence and medication errors.^8,10 These findings indicate that the complexity of the medication regimen could be an important underlying factor driving caregiver involvement in medication management, and merits further investigation.

A final important factor related to caregiver medication management was the location or living situation of the caregiver and care recipient. The existing literature has shown a mixed relationship between living situation and caregiver involvement in medication management. Arlt et al.⁸ suggested that the living situation must be taken into consideration when developing medication adherence strategies. However, Noureldin and Plake⁵ investigated the relationship between living situation and caregiver involvement in medication management activities and found a significant relationship only for tracking medications and not for ordering or injecting medications. Our findings add additional context and detail on how location can impact caregiver medication management. Our findings suggest that while factors such as care recipient independence and health and function may be determinants of need for caregiver assistance with medications, location primarily influences the ways in which medication management is performed by caregivers.

Interestingly, the caregivers themselves perceived little or no impact of living in a rural area on their ability to manage medications. However, concerns were raised about pharmacy closures and a lack of pharmacy access, which is consistent with trends in rural community pharmacy closures that have been experienced nationally.²⁵ In addition, difficulties with limited availability of health care services, long travel times, and lower quality care are well documented issues facing rural residents.²⁶ Efforts to support rural informal caregivers with medication management need to take into consideration the unique health care landscape within which such care is being provided, which can include factors such as the pharmacies and health care facilities in the area, transportation needs of the caregivers, and local caregiving and social support services.

Limitations

Several limitations of this study have been previously described elsewhere, including the use of a convenience sample of rural caregivers from one county, and the use of caution when generalizing the findings to a wider population of caregivers.⁶ Of particular note, this study only assessed medication management from the caregiver’s perspective; it is important that future studies consider the perspectives of both caregivers and care recipients to assess whether they share similar or divergent perspectives. In addition, caregivers that participated in the focus groups may differ non-participants, such as being more involved in medication management or facing more or less challenges than those who did not. Finally, further research using an alternative method such as a survey with a larger sample size of both urban and rural caregivers would be helpful to explore the relationships between the characteristics of the caregivers and care recipients and the identified themes and sub-themes in more detail.

Conclusions

Interventions and pharmacy services to support medication management by rural informal caregivers should be designed in a way that preserves and promotes the care recipient’s independence as much as possible. In addition, pharmacists and other health care providers should take into consideration factors such as care recipient health and function and location when developing such interventions and services, and should be adapted to the specific caregiving situation, as the tools and strategies needed to support caregiver medication management may vary based on these and related factors.⁶ Further research on the relationships between these factors may be useful to inform the development of theoretical frameworks to support caregiver medication management.