User Insights for Design of an Antihypertensive Medication Management Application

Abstract

Hypertension is the most common chronic disease affecting older adults (65+) in the United States. Unfortunately, many struggle to adhere to their antihypertensive medications as only about half diagnosed with the disease have it controlled. Therefore, there is a need for designing supportive medication management systems to aid this population with their antihypertensive medications, especially using increasingly adopted technologies such as smartphones. The preferences of older adults with hypertension must be considered when designing such systems for this population. Six older adults participated in structured interviews to inform the design of the Medication Education, Decision Support, Reminding and Monitoring System (MEDSReM). Results revealed management needs, design insights, and reminder preferences, as well as mostly positive opinions regarding technology use for medication management. These findings informed the development of MEDSReM with the goal of supporting older adults in successfully managing their antihypertensive medications.

INTRODUCTION

Hypertension, a condition in which an individual’s blood pressure is elevated above levels considered healthy, is the most common chronic condition impacting older adults over the age of 65 in the United States as approximately 70% of this population has been diagnosed with the disease (National Center for Health Statistics, 2017). Moreover, with the recent reclassification of the hypertension diagnosis criteria, what used to be known as “prehypertension” is now deemed stage 1 hypertension, thereby increasing the number of individuals with the condition (Whelton et al., 2017). Hypertension, if untreated, can lead to severe complications that can significantly reduce one’s quality of life and increase the probability of premature death, such as kidney disease, ischemic heart disease, myocardial infarction, stroke, among others (Centers for Disease Control and Prevention, 2014).

With the high prevalence of hypertension and the impact that it may have on individuals if it remains unmanaged, there is a need to ensure that individuals diagnosed with the condition are able to effectively perform the behaviors necessary for successful treatment. This is especially true for older adults who have elevated risk for memory declines (e.g., episodic, prospective, and working memory) that may affect their ability to consistently and effectively manage their health (e.g., Luo & Craik, 2008). Compounding these potential age-related memory challenges, individuals living with hypertension may experience declines in prospective memory related to the disease itself, further disadvantaging consistent management (Scullin et al., 2017).

A challenging characteristic of hypertension is that it is mostly asymptomatic, meaning that an individual is generally unable to perceive when their blood pressure is elevated unless it has risen to a level that puts them at risk for a “hypertensive crisis.” This is an extremely high, and relatively rare, blood pressure that can induce physical symptoms such as vomiting, severe headaches, and chest pain. However, for most individuals, the elevated blood pressure they experience is imperceptible, which may compound the difficulty of managing hypertension for an older adult experiencing memory decline. Additionally, events that interrupt one’s usual adherence routine, or living a busier lifestyle in general, negatively impact medication adherence (e.g., Park et al., 1999). This may be consequential, as consistently and properly adhering to one’s prescribed antihypertensive medication is one of the primary defenses an individual has to control the disease. Such difficulties are exemplified by the fact only about half of older adults (60+) have their hypertension controlled, and medication nonadherence has been found to be one of the primary contributors to this lack of control (Fryar, Ostchega, Hales, Zhang, & Kruszon-Moran, 2017; Ho, Bryson, & Rumsfeld, 2009).

To address issues of nonadherence in older adults, there is a need for effective interventions that lead to improved management of their medications. Insel and colleagues (2016) developed and administered a multifaceted prospective memory intervention that successfully increased the adherence rates of a sample of 58 older adults (65+) who were found to be nonadherent as measured with the use of the Medication Event Monitoring System (MEMS®; i.e., an electronic pill bottle cap capable of recording when the pills were accessed). These benefits were in comparison to an education control condition and were most apparent for those with lower cognitive function per an executive function/working memory composite score. Although this intervention led to positive results, consistent adherence was not maintained over time as nonadherence rates returned to near baseline within five months of the intervention’s cessation. Thus, there is a need to provide similar supports for antihypertensive medication adherence that will persist over time, and technology-based medication management systems show promise in addressing this need.

According to Anderson and Perrin (2017), the use of smartphones among the older adult population has increased significantly in recent years, with about 40% of adults 65 years or older in the United States now owning such a device. The proliferation of these devices provides a potentially beneficial medium for delivering medication management information. Such information includes details about one’s current antihypertensive medications, decision support for taking missed or forgotten medications, reminders to take a dose, and monitoring of adherence patterns. In comparison to low-cost reminder devices, which have not shown strong evidence for improving medication adherence, the additional features and portability of smartphones may allow for more effective means of delivering the older adult the information they need, when the need it (Choudhry et al., 2017; Thakker et al., 2016).

The potential benefits of providing accessible and relevant educational information, decision support, reminders, and monitoring functionality for older adults to manage their antihypertensive medications led to the development of the Medication Education, Decision Support, Reminding and Monitoring System (MEDSReM). Providing such a system via their smartphone could help older adults stay better informed about their medications and aid them to effectively follow their prescribed regimens. However, for such a system to be effective, it is imperative that the opinions and preferences of older adult users are considered to ensure that MEDSReM is designed with their needs in mind. This is especially true as accepting these technologies depends on a relatively complex interplay of diverse factors (e.g., concerns, expected benefits; Peek et al., 2014). Thus, the purpose of the current study was to better understand older adults’ perspectives on issues relevant to the design of MEDSReM through structured interviews. The overarching goal of the interviews was to determine patient-derived user requirements relevant to information and task needs regarding medication-taking behavior in the context of technology.

METHOD

To investigate topics relevant to antihypertensive medication management and preferences regarding technology systems to support this management, we interviewed six older adults over age 65. Participant consent was obtained via informed consent form, and all participants were compensated for their time.

Participants

Six older adults participated in the study. All participants had been prescribed at least one antihypertensive medication that they had to manage. For participant characteristics, see Table 1.

Table 1.

Participant Characteristics

Variable	Frequency
Total Participants	6
Age (Years), Mean (SD)	79.33 (5.50)
Gender, N (%)
Female	3 (50%)
Male	3 (50%)
Race, N (%)
Asian	1 (16.67 %)
White	5 (83.33 %)
Education, N (%)
Some college	1 (16.67 %)
Bachelor’s	1 (16.67 %)
Master’s	4 (66.67 %)
Self-reported Health, N (%)
Good	2 (33.33 %)
Very good	4 (66.67 %)

Measures

Structured interviews.

A structured interview was designed that asked participants 16 questions regarding their experiences with their hypertension diagnosis, their approaches to remembering to take their antihypertensive medications, common events or experiences that have inhibited proper adherence, and preferences related to medication reminders delivered by technology.

Analysis

An inductive qualitative analysis was performed on the content of the interview data to identify common themes relevant for designing and developing MEDSReM. This approach allows “…findings to emerge from the frequent, dominant or significant themes inherent in raw data, without the restraints imposed by structured methodologies” (Thomas, 2003, p. 2). Two evaluators reviewed the interview responses individually, noting the common and relevant themes. They discussed any discrepancies between the analyses until consensus was reached. Overall, common topics that arose across participants regarding the factors relevant to designing a supportive educational and reminder system for antihypertensive medication adherence were thus identified.

RESULTS

Antihypertensive Medication Adherence

To provide context for participants’ needs and opinions regarding an antihypertensive medication education, decision support, reminder, and monitoring application, it was necessary to understand their current experiences with their medication adherence. Thus, we asked participants to reflect upon their past experiences with their medication and attempts to adhere to their prescribed regimen. All participants self-reported that they had been prescribed at least one antihypertensive medication, which they had been attempting to manage for at least 20 years.

A common theme among participants’ responses was their high intentions for taking their blood pressure medication as prescribed. All participants reflected that it was something that they needed to do each day. For example, one participant, when asked to reflect on why they felt this way, responded, “Well, I wanna live and be healthy, as healthy as I can be…” Although the sources of these intentions varied, from internal motivation, to avoiding the potential consequences of the disease, to the desire to follow their doctors’ orders, each participant viewed proper antihypertensive medication adherence as something that was important for their health that should be consistently pursued.

Participants noted use of a reminder process, or routine, for helping to remember to take their antihypertensive medications, although there was notable variation in their approaches. Such reminder strategies included the use of pill organizers; associating the ingestion of medication with other common and repeated events such as brushing one’s teeth; social reminders (e.g., spousal assistance); and keeping their medication in specific and consistent locations so they notice it at the appropriate times. Participants perceived these routines as helpful for remembering, and a common theme across participants was that they may experience difficulty adhering to their medication if they were busy or if their “routine changes,” referencing interfering events such as “having dinner before, talking with a friend…,” among others.

Decision Support and Perceived Knowledge

We asked participants what they would do if they realized they had forgotten to take their medications. These medications may have important dosage windows that, if not considered, can lead to unsafe levels of the medication within a person’s system and cause their blood pressure to drop significantly. These windows may vary depending on the prescribed medication but should be taken into account when one is deciding whether to take a missed dose.

A commonly held perspective among most participants involved taking the missed medication as soon as they were able to, either right away or when they arrived back at home if they were away. For example, one participant stated, “If I hadn’t taken it and I thought of it during, maybe when I was on my run…then I’d do it as soon as I got home.” Antihypertensive medications tend to have general, sometimes vague, recommendations regarding these windows which should be considered if a dose is missed, and a number of participants expressed uncertainty regarding when they should take a dose or skip it. One participant, when presented with a scenario in which they realized they had forgotten to take their medication, stated that they “might take the evening one early,” depending on how close they were to that dose window. Another individual stated that, depending on how late it was, that they would “probably just skip it.”

Perceived knowledge about hypertension and prescribed medications may influence the choices a person makes concerning how to manage the disease. Thus, having accurate information about the consequences of the disease or the medication they are taking can inform proper adherence-related actions and successful outcomes. Still, there were differences among participants regarding their knowledge of hypertension’s generally asymptomatic nature. For example, one participant stated that there were “no symptoms,” even mentioning being “surprised” by their diagnosis as they did not feel the disease’s effects, a commonly held realization of those diagnosed with hypertension. In contrast, three other participants described that they will feel “spacey,” they perceive an increased chance of “falling,” and that they just “didn’t feel well” when not taking their medication. Thus, there was an apparent divide between participants regarding their understandings of the disease and the effects of their prescribed antihypertensive medications.

Information Presentation and Utility

We asked participants to share their preferences regarding what and how information relevant to managing their blood pressure should be presented to them as MEDSReM was being designed to include an educational component that could inform them about their medications. A common theme among responses involved the desire for having easy access to up-to-date medication information in a clear and concise manner. For example, one participant stated they desired information such as whether “…you can take it with food or not. How often you need to take it. Probably, if it’s a new prescription for you, you need to be aware that there may be side effects and to be watching for anything that’s different.” To receive this information, the same individual requested, “there oughta be like a bullet list, the important [things]. And that might trigger having someone, if they’re having a little question or other, then they could go to read further… Kind of an outline for them…” Similar opinions were echoed about not overcomplicating the presentation, or to “keep it simple.”

An important characteristic of the proposed MEDSReM application is that it utilizes technology as a medium to deliver information, whether that information be educational, decision-related, or dose reminders. With this in mind, we asked participants questions regarding their preferences for looking up information if they needed to, as well as their opinions on using technologies to find that information. Participants generally expressed a willingness to use technology to find the information they needed. “I have the dictionary on my iPhone. I can look things up on that. Medications,” expressed one participant. Additionally, when asked about what methods they would like to use to look up desired information, most participants expressed that technological media (e.g., using the internet on a connected device) were favorable.

Reminder and Monitoring Preferences

A central component of MEDSReM is delivering reminders for individuals to take their antihypertensive medications connected to routine activities, and to provide that reminder in a manner that the user prefers. We asked participants about their opinions on reminder characteristics. Those who had experience using reminders with smartphones, such as setting alarms to notify them of certain events, felt positive about their past experiences. Not every individual felt this way, however. “No. Ewe. Ick. I turn ‘em off on all my devices and everything. I don’t like alarms,” said one participant when asked if they had ever used an alarm reminder.

There was a general preference across participants for reminders that beeped and/or vibrated. Moreover, if the reminder was being delivered via their smartphone, a text message or alarm was viewed more highly than other methods such as voice or phone call. Their general reasoning stemmed from wanting to be alerted in a discrete manner, and this preference was upheld whether they were at or away from home. This was aptly summarized by a participant who, when asked what reminder methods they would not like, stated that they would not like “anything that’s loud…or intrusive.” Additionally, another participant who felt similarly expressed that, “the noise that could go off in a movie theater…Heaven knows, what if you forget? When it bothers people other than just your very own self…I don’t like that.”

On a similar note, participants generally did not view the system inquiring whether they had taken their medication as favorable, as they would view it as “more annoying than not…” and that a user would begin to “resent” the system. Still, it should be noted that some divide among opinions existed. Some participants did not consider technological reminders and monitoring as preferable to more traditional techniques such as their established routines, while others seemed open to the potential of these approaches.

Opinions on the Proposed MEDSReM Application

Closing the interview, participants were informed of the three primary features of MEDSReM. Specifically, they were told that, “first, it would provide information about medication; second, it would remind you to take your medication and help you check to see if you had taken it as intended; and third, it would help you to decide if you can safely take your medication when you have forgotten.” When asked about their opinions of the proposed system, all participants believed that it would be helpful. Reasons provided included that it “takes all the decision making away from me,” “it could also give you cautions and other things that may be important,” and that the reminders would benefit them because their “memory is not as sharp as it used to be…there is a lot of things [they] don’t remember.” One participant expressed that the proposed system’s development was “exciting.”

Finally, we asked participants which component of the three aforementioned system components they viewed as most helpful. The educational component, which included providing information about the medications one was prescribed, was viewed to be the most important as it could help individuals better understand, “what the heck these things are that [they’re] taking.” The second component that was viewed most favorably was the reminder function, as it would help one remember if they “need to take it within a certain time.”

DISCUSSION

Participants’ responses to the structured interview questions provided valuable information to aid with the development of MEDSReM. Understanding their experiences with antihypertensive medication management and their preferences regarding educational, decision making, reminder, and monitoring supports to help achieve successful adherence informed the design and features of the application. Moreover, the participants made it clear that properly and consistently taking their medication was something they viewed as important for a variety of reasons, suggesting a willingness to use, and a need for, supportive systems such as MEDSReM.

Regarding how participants attempted to adhere to their antihypertensive medications, there was a clear importance of the routines they used to remind them when to take their medication. Furthermore, the fact that participants commonly expressed that being busy or experiencing events that interfered with these routines led to adherence failures accentuated this point. Thus, the utility of MEDSReM in providing additional support to reinforce medication-taking behaviors linked to these routines and help remind the individual to take their medications may reduce the frequency of nonadherence.

Ensuring that older adults managing their hypertension have an accurate understanding of the disease and the characteristics of their prescribed medications is imperative to properly and safely treat the disease. Without this knowledge, older adults might make uninformed management decisions such as taking their medications outside of the recommended dosage windows following a missed dose or believing that their hypertension is properly controlled because they feel well despite the disease’s generally asymptomatic nature. Participants’ diverse and relatively uncertain answers to the interview questions regarding these topics portrayed the need to provide accurate and easily accessible disease and personalized medication information. Thus, integrating this information into MEDSReM can support better management decisions for individuals with hypertension. Additionally, it removes the need to remember detailed medication ingestion instructions, a task that might be more difficult for an older adult to remember due to the potential influence of age-related memory declines.

An important characteristic of MEDSReM is that it delivers the educational, decision support, reminder, and monitoring information through a smartphone application. There are many benefits to using such a device, especially as smartphones have seen increased acceptance among all populations in recent years. Therefore, for an older adult to use this application, they need to be willing to use such technologies. Participants in the current study expressed that they were open to the use of the device for the proposed purposes of the system. All participants viewed the purpose of the system and its individual functions as potentially helpful for managing antihypertensive medications, with the educational features most valued. This exemplifies that there is a potentially high utility for systems such as MEDSReM to provide medication management support and contradicts the commonly held stereotype that a negative relationship between older adults and technology use exists.

Although many commonalities were present among participants’ comments regarding needs, design preferences, and general opinions, there was also variability among responses. The reported findings reflected the general opinions of the participants, but this did not always mean that they were in complete agreement regarding each proposed topic. As previously mentioned, although the majority of participants viewed technology as a medium that could be useful in delivering medication reminders, not all reminder methods were viewed as useful and these views varied among participants. This highlights the importance of designing a system that includes options for the individual to customize the experience to reflect their needs.

One limitation of the current study was that the sample size was small, with only six participants sharing their opinions on the topic. Still this approach was more than sufficient for the purpose of the study: to aid in determining patient-derived user requirements relevant to information and task needs regarding medication behavior in the context of technology, thus supporting the design of MEDSReM. A larger sample may have led to a richer set of perspectives, but the foundation laid by the information participants shared was informative for our needs and provided an initial glimpse into the directions that development of MEDSReM should proceed. Additionally, although not necessarily a limitation, the inductive qualitative approach taken in the current study extracted only the general opinions and themes from participants’ responses. Although informative for our needs in designing the MEDSReM application, other qualitative approaches such as frequency or semantic analyses might reveal more detail regarding participants’ approaches, opinions, and preferences.

The information from the structured interviews provided insights for the needs analysis for development of MEDSReM. Future work will include testing the prototype to ensure that the system properly merges the needs and preferences of older adults managing hypertension with human factors design considerations. These assessments will yield an effective system to support antihypertensive medication management and improve the overall quality of life for older adults managing their high blood pressure.