An Interpretative Phenomenological Analysis of the Experience of Taking Medication to Prevent a Further Heart Attack

Following an acute myocardial infarction, patients are prescribed a regime of cardio-protective medication to prevent recurrent cardiovascular events and mortality. Adherence to medication is poor in this patient group, and not fully understood. Current interventions have made limited improvements but are based upon presumed principles. Aim To describe the phenomenon of medicine-taking for an individual taking medication for secondary prevention for an AMI. Method Interpretative Phenomenological Analysis was used to analyse transcripts of semi-structured interviews with participants. Themes were generated for each participant, then summarised across participants. key to compare themselves to showed that their was to them, discussed how the future was an unknown entity for them, had their and to their reduced their


Introduction
Cardiovascular disease currently causes over 4 million deaths annually in Europe [1]. Acute myocardial infarction (AMI) is responsible for the largest proportion of these, estimated to be 15% of the total [2]. In the UK, just under one million people are thought to be AMI survivors [3].
Following an AMI, a combination of ve different classes of medicines are recommended as part of treatment guidelines for secondary prevention in the UK [4], the US [5], and Europe [6]. A meta-analysis of these drug groups has found that following the ve-drug therapy confers a 40% reduction in mortality and 25% reduction in cardiovascular events [7]. Whilst a broader study in coronary heart disease patients, it found that the reduction in all-cause mortality and cardiovascular events was due to an additive effect.
This highlights the importance of taking these drugs in accordance with the prescription issued by a health professional.
Medicine adherence is de ned as "the extent to which a patient's behaviour matches agreed recommendations from the prescriber" [8]. Meta-analytic data from 376,162 patients has shown the level of adherence in patients taking medicines for secondary prevention of AMI to be 66% [9]. This study found no other statistically signi cant differences between the drug classes, which suggests that nonadherence is not related to a drug class characteristic, such as a drug side-effect, but to other factors.
Because non-adherence in AMI increases one-year mortality, hospitalisations and costs [10], it follows that improving medicine adherence should then reduce patient mortality, morbidity and healthcare system costs.
Improving medicine adherence has been a focus for the World Health Organisation (WHO) [11], which famously reported that "increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in speci c medical treatments".
In the UK, the standards of practice for the NHS are determined by the National Institute for Health and Care Excellence (NICE), which has produced treatment guidelines for improving medicine adherence [12].
This report acknowledges the need to understand patient perceptions of their medicine along with the physical practical support that can be given to aid patient adherence. It recommends that adherence is supported through patient involvement in decision-making, offering information, and being aware of patient concerns.
There has been much research into nding effective interventions, yet many are complicated and eventually unsuccessful in terms of improving medicine adherence and clinical outcomes [13]. Most adherence research uses quantitative methods to determine adherence as an outcome, with a thin evidence base underpinning the theoretical framework. A study of the data from adherence studies concluded that most interventions are not produced as a result of theoretical models [14], even though interventions aimed at changing behaviour have been shown to be more effective when based upon theoretical models [15]. Therefore, a qualitative approach would be useful to generate themes and propose models which could ratify conceptual frameworks and direct further work in quantitative studies.
Historically, there is a lack of qualitative research into medicine adherence [16].
Consistent with a patient-centred approach, a qualitative phenomenological study is appropriate to obtain a patient perspective of the experience of taking medicines, beliefs, and how patients conceptualise their medicines within their lives [17]. In addition, a study that includes an exploration of the social context and lived world of a patient would be appropriate, and an ethnographic patient interview is suited to this purpose [18].

Aim of the Study
To describe the experience of an individual taking medication to prevent a further AMI, and factors that in uence their medicine-taking ability.

Ethics Approval
This study was approved by the University of Reading Ethics Committee (Reference UREC18/36).

Methods
All methods were carried out in accordance with COREQ guidelines [19]. A sample size of four participants was chosen to enable a quality analysis to take place, to ensure thoroughness, depth and maintain ideography of the analysis, consistent with an Interpretative Phenomenological Analysis (IPA) study [20].
Participants were recruited using a promotional poster cascaded by email within the University of Reading, which was also sent to targeted cardiac support groups within the locality of the South-East region of the UK. The criteria for inclusion were adult individuals with a diagnosis of AMI and who had been prescribed medication for secondary prevention of AMI.
Initial contact was made through email with the rst author, HP, the study information was distributed, and written informed consent was obtained from all the study participants in person or via email. Prior to interview, participants were assigned a pseudonym. All participants who made initial contact followed through to full interview.
All interviews were conducted by HP in a private o ce room, either face to face or over the telephone, between June 2019 and January 2020. The interviews ranged in duration from 17 minutes to 65 minutes, and average time of 48 minutes.
A semi-structured interview schedule was used to guide the interviews. The schedule was informed by one used in a similar medicine adherence phenomenological study [21], and more general literature on developing interview protocol [22]. Following the rst interview, the schedule was re ned in accordance with a self-re ective 'interview the interviewer' technique [23], the nal schedule can be found in Additional Information. All listed questions were put to the participants, and during the interview, further lines of questioning and probes were added in response to answers given by the participant as the interview progressed.
Field notes were taken by HP during the interviews as an aid to topic coverage. Immediately following the interview, notes were made on meaning of discussion topics, to aid in the analysis. The notebook was used during the transcription and analysis stages also, to add a re exive commentary on the researcher's thoughts and sense-making process.
Interviews were audio-recorded to MP3 le, which was transcribed verbatim by HP into an MS Word text document. The transcripts were checked alongside the audio to con rm accuracy. In line with a transparent study, participants were sent a copy of their transcript. No participants disagreed with the content of their transcript.
Analysis was undertaken according to IPA [20]. All transcripts were analysed by HP, a novice qualitative researcher, PhD student and practicing pharmacist. The transcripts were read a minimum of twice, and line-by-line notes made using an IPA stance, a description of the meaning and understanding by the researcher of the participant's statements. The rst transcript notes were discussed with PD, an experienced qualitative researcher and Professor of pharmacy practice, with specialisms in anthropology and psychology. This discussion generated further notes, consistent with a "mini-independent audit" [20], a check of validity. This discussion of notes was repeated for the second transcript.
Lifeworld framework categories of time, location, embodiment and relationships were used as an initial means of organising and arranging the notes [24]. The transcript notes were colour-highlighted by lifeworld category and grouped.
Following the rst sift into lifeworld groups, the transcript notes were coded into thematic groups, collected together according to concept. These groups were used to write a participant summary document in prose, which described each individual, arranged by lifeworld category. In line with IPA, preservation of the participant's voice is important, and so the original interview quotes were used to illustrate themes. Analysis was repeated for each transcript and a summary document was produced for each participant.
The summaries of themes for each participant were grouped together, using overarching themes that encompassed all the concepts encoded in the themes that they described. These were the superordinate themes that featured across all the participants' transcripts. These superordinate themes were organised into tables illustrated with the original text quotes from each participant which are presented in the results section below.

Results
The participants (n = 4, 2 women, 2 men) discussed medicine taking through four superordinate themes (Table 1); they compared themselves to others, knowledge was important to them, they considered the future in some form, and they discussed ways that they tted their medicines into their lifestyle. A related theme to lifestyle, all participants discussed how a change to their routine adversely affected their medicine taking. They all described their AMI as a "heart attack", and so this term is used henceforth. The superordinate themes are presented with interview quotes for Gaye (Table 2), Beki (Table 3), Chris (Table 4) and Colin (Table 5).     One of the superordinate themes was the way in which participants focussed on their history and lifestyle leading up to their heart attack in reference to other people, often evidencing that they were in a superior position, and as proof that their body was healthier by managing to survive the heart attack.
They frequently gave examples of how they were health conscious. They considered that vegetarianism, non-smoking, training for a marathon, preparing for pregnancy, and gym attendance to be attributes that made their health superior. Most participants were keen to point out how they are different from 'normal' heart attack patients, in terms of healthy living status, gender, age and type of heart attack. They used their own biometric results to compare their health to normal ranges as justi cation that their health is comparable to 'normal'. They also described similar diagnoses in acquaintances, friends and relatives to discuss how their case was different, with the implication that their case was less morbid. Colin de ned himself in terms of luck.

Knowledge
The superordinate theme of knowledge encompassed a range of themes that included questioning the cause of their heart attack and need of their medicines, seeking information, having a theoretical and practical knowledge of their medicines, sharing information with others and receiving support as part of a group. The category of knowledge also encompassed self-perception, including participants' understanding of their own medical status, tness, and medication.
All participants were able to describe their medicines and medical treatments. In addition, they showed curiosity to know about their treatment, either nding answers themselves or using the knowledge of others. Gaye articulated her lack of knowledge about her medicines.
All the participants could recall the names, timings and strengths of their medicines, often referring to paper copies of medical notes during their interview, although these were not requested by the researcher. They found information through hospital consultants, GPs, acquaintances, family, support group and rehab group members. They used sources such as medicine information lea ets and academic-level databases. Two participants sought the knowledge of a private consultant, reasoning that the consultants' professional status conferred a better level of care. One participant linked private healthcare with receiving better care and economic status.

Considering the Future
This superordinate theme was drawn out by all participants as they invoked the idea of the future in all their narratives. Gaye, Beki and Colin all mentioned taking medicines continuously into the future, using an almost identical phraseology of "having to take these forever", and Beki's "every day for the rest of my life".
Gaye mentioned that the future is unknown in terms of heart health, and Beki considered that another heart attack is possible. Colin used the future conditional tense as he talked about having taken his medicine for such a long time "it had built up inside", and that if he missed a dose, it "shouldn't be a problem".

Assimilation into Lifestyle
Another broad superordinate theme was assimilation of medication into the participants' lives. All participants relayed how they accommodate their medicines into their everyday routine in a unique way. This group included themes of personal relationships, medicine location, systems and adaptations.
Gaye and Colin discussed being overwhelmed initially, but then how taking medication has become part of their everyday life. They both described the routine they had created, now as unremarkable and not noticeable. Both Beki and Chris mentioned a di culty, Beki because of the side-effect, and Chris because of the extra quantity to remember, but they persisted with their set treatment.
Gaye began with swallowing di culties but was given a "tip" by a pharmacist, and now takes medications simultaneously with a grape.
The location of medication was discussed as a practical decision or based upon their beliefs. Beki sites her medication in her kitchen, "out of the way" as her son's safety is a priority. Chris decants all packaging and keeps them mixed in a Tupperware box, as an e ciency measure. Colin keeps his medication in a pouch which remains in one location at home, his GTN spray is the only item that he will carry in his pocket whilst at the gym.
Beki discussed how her pregnancy took priority over her medicine taking, as she stopped taking some of her medicines.
Chris and Colin talked about medicine-taking as an effortless activity, both using the analogy of coffee and tea-drinking to describe the automatic nature of taking medicines. Chris compared cultural drinking to taking different medicines, "coffee for that, wine for this".
Neither Chris and Colin were concerned about missing doses, Chris reasoning that missing medicines wasn't life-threatening, and Colin because he doesn't notice any difference.

Disturbance to Routine
All the participants discussed how a disturbance to their daily routine could result in their missing a dose of medication. Disturbances included being away from home, being on holiday, and distraction by another activity.
Being away from home was discussed as a reason by all participants. Gaye talked about going out and forgetting her evening dose of statin. Beki suggested that she might be out and forget to take a dose.
Chris took his medicine box out with him to ensure he didn't miss doses.
Colin's wife gave him verbal reminders when away on holiday and he mentioned different time zones causing confusion.
Chris gave the example of being absorbed on the internet and so went to bed without taking the evening dose. Colin discussed missing doses when his family came to stay at his home.

Discussion
This study has produced themes that add to our understanding of the experience of medicine taking following a myocardial infarction. The participants discussed medicine taking through four superordinate themes. Firstly, they compared themselves to others, often using this comparison to bolster their sense of wellbeing and provide optimism about themselves. Secondly, knowledge was important to them, to help them construct an understanding of their condition and its management. Thirdly, the participants all considered the future in some form, thinking of it as either a constant or an unknown concept. Fourthly, participants discussed ways that they tted their medicines into their lifestyle each making unique adaptations to manage their individual medicines. A related theme to lifestyle, all participants discussed how a change to their routine adversely affected their medicine taking. The study offers an interpretivist perspective in an area weighted towards quantitative research. The themes provide patients' perspectives on medication, extending beyond the simple representation of adherence as either intentional or unintentional, helping therefore to give context to people's engagement with medication following a myocardial infarction. These themes could help guide practitioners to provide more patient-centred care in future health consultations. They also show that patients adapt medicine taking into their lives in various and unique ways and a tailored approach to support them would be appropriate.
Currently medicine adherence support is provided to this patient group at the primary healthcare level through GP services, where the main aim is to integrate hospital discharge and return to independent home living through a programme of cardiac rehabilitation. While social support and cardiac rehabilitation have been well documented to improve treatment outcomes and quality of life measures, it is also apparent that recovery is a complicated and multifactorial phenomenon. An important positioning paper by the European Association of Cardiovascular Prevention and Rehabilitation highlights the complex role that psychosocial-related factors play in both the genesis and recovery of CHD [25]. For example, psychosocial factors such as stress, anxiety and depression are implicated in the development of CHD, can be caused by CHD, and even reduced by CHD-the latter occurring when family rally round to increase social support following a diagnosis. The paper also discusses the complex ways that psychosocial factors in uence cardiac outcomes and recovery, and how these factors can overlap and work in multiple directions, for example acting as barriers to lifestyle changes and treatment adherence. This complexity is in line with the themes untangled in this analysis, some of which conceptually overlap and affect one another, further emphasising the need for a patient-centred approach.
The theme of comparison to others and seeing one's own health protective behaviours as superior to others, could be construed as participants' way of evidencing their own health, maintaining control, and/or providing self-reassurance. This theme of comparison to others was also discussed in a narrative analysis of patients taking anticoagulant medicines to prevent stroke [26]. In that study, participants also constructed themselves as superior to others, evidencing their good intentions for example as good adherers while non-adherers were 'wasteful' or 'ungrateful'. Although a study of a different patient group, it agrees with this study that participants were keen to portray themselves as being healthy, adhering to medicines and positive lifestyle measures, and seeing others as having less favourable circumstances in terms of health. They found that missing doses was described as due to external circumstances of timing and location, and not linked to a personal trait. This supports the notion that participants are constructing an identity of positive health and higher morals than others to nd comfort and gain control away from the tension of the uncertain. This nding highlights the need to consider the individual within group activities such as cardiac rehabilitation and social support groups, or when discussing bene ts of treatment in terms of 'most patients'.
In the current study, the theme of knowledge is important because of its role in creating coherence whereby a clear model of treatment helps participants remove uncertainty and regain control of their self over their illness. Another study of the meaning of medication to patients also explored the role that knowledge and meaning play in helping patients understand and manage their medication [27]. That study found the medication experience to be a meaningful encounter, with positive or negative bodily effects, and an unremitting nature which could cause patients to question the need for it. The patients could even exert control over the medication through the expertise gained from taking it (e.g., take the medication only 'when required'). Parallels can be drawn with the current study under the themes of both knowledge and assimilation into lifestyle, as participants described their own experience of medication effects and side effects, sometimes questioning the need to take medication, and importantly, gaining control over the medication by simply taking it and not feeling it was unwarranted. This emphasis on meaning-making could be thought of as a learning process and therefore prompt practitioners to think about where a patient is in their learning journey when delivering patient-centred care.
Similarly, the theme of thinking about the future could add to a sense of coherence and continuity. It is noteworthy that medicines adherence is not often framed in relation to the concept of the future. In pharmacy, the professional focus is traditionally upon medical history and the future extends only as far as the patient's current valid prescription. The use of electronic transfer of record keeping, sharing, prescribing, and repeat batches of prescriptions, however, is potentially of bene t in terms of framing the future. This suggests more work could be done to investigate the impact of the current model of monthly prescriptions on patients' sense of their future and in turn their medication adherence.
Medicine-taking exists within the constructed life-world of the patient, affects and is affected by it. The theme of tting into lifestyle, drawn out in this study, highlights the interconnectedness of medicines and patients' life-world. In this study patients had incorporated their medicines into their lives in unique and speci c ways that were important to them and their beliefs. This adds further weight to the argument that reducing medicine-taking to 'cause and effect' is over-simplistic and of limited practical use. Against the good adherence work that the participants discussed, missing doses was attributed to being distracted, away from home, and timing issues. This is similar to the ndings of a qualitative interview study of unintentional non-adherers taking medication for chronic conditions [28], which found schedule change, life pressures, and location change to be reasons for adherence failure, suggesting that work to improve adherence should focus on these routine-related factors. The theme of 'change to routine' is arguably not disease-speci c but associated with medication taking in chronic illness more generally. Routine is rooted in physicality, related to time, space and occupation, which could all be manipulated through behaviour change therapies in order to remove practical and perceived barriers to taking medicines [29]. However, this type of intervention might only be relevant where patients are unintentional non-adherers, who aim to be good adherers (compared to others), rather than for intentional non-adherers who have no intention of taking medicines to start with.
A rich, detailed description of the lived experience of medication taking was achieved by the devotion of time, care and attention to the analysis. By using a case study approach, the results cannot claim to be exhaustive as there is no endpoint at data saturation as found in some qualitative methodologies.
However, the use of comparison between cases has elicited superordinate themes for further investigation. In line with the ideographic nature of an IPA study, the results are not generalisable to larger populations but could be cautiously broadened to establish how they t amongst different groups. IPA requires a heterogeneity of sample, and this was achieved through purposive selection of participants as those tting the inclusion criteria, their locality to the South-East of England and having a similar socio-economic pro le. An equal gender mix was observed, but results were not de-aggregated, contrary to SAGER guidelines [26]. The rationale for this was the small participant number and ideography of an IPA methodology, where the focus is individual voice, and summary of detailed themes resonating through those voices, as opposed to a broader aggregation of themes.
The self-selection bias of participants may have affected the result of this study, as perhaps volunteers tend towards individuals with positive or more extreme experiences. The situational pressure of an interview may have contributed to the participants feeling obliged to satisfy the researcher's line of questioning and present themselves in the best possible light, in the same way that a medical consultation might do [30]. The method of analysis, IPA, is a close rst-person study, and so the participant is interpreted as being truthful and without agenda. Future study to examine the performance and politics of the talk during the same interviews could be completed using discourse or conversation analysis as a more critical method.
The use of IPA tted well with the research question and compliments the model of patient-centred care where empathy and understanding are valued. This study has shown that whilst generalisations can be made, each patient's experience is unique and the meaning they associate to their behaviour and action is very personal. Therefore, the case study approach to developing medicine-taking interventions is a valid one. This is congruent with NICE recommendations for medicine adherence support to be patient-centred with interventions adapted to individuals [12], and future work to be directed towards this area. This patient-centredness could be practised in pharmacy by way of motivational interviewing as an aid to medicine adherence, which in the UK is not currently a standard practice within the NHS.
Whilst ful lling the aim of describing the medicine-taking experience, the relationship to medication adherence, and more importantly, non-adherence is unclear. All the patients discussed rarely missing their doses, and so perhaps future studies could solely include the elusive volunteer group of non-adherent patients. This echoes the ndings of the Cochrane review of adherence interventions [13], which concluded that more work ought to be completed with patients whose adherence is low.

Conclusion
This study found the meaning of medicine-taking in this participant group was oriented towards reducing the unknown and reinforcing stability and cohesion in their lives. This nding, alongside the themes that the analysis generated could help practitioners assisting patients in their medicine-taking experience. The theme of comparison to others was found to confer a moral superiority to the self and offers comfort against uncertainty. The theme of knowledge and looking towards the future contributed to a participant's sense of coherence, again reducing anxiety of the unknown. Assimilation into lifestyle could be considered a modi able learned behaviour, and medication routines could be strengthened by activity, location and timing interventions.
Meaning making was unique to individuals and so adherence interventions should be tailored to personal experiences in order to be more empathetic and therefore more impactful for an individual patient.
The methodology highlighted the importance of considering the phenomena of adherence as part of the whole life of an individual, as it is the entirety of a patient's world that imparts meaning to adherence. The ideographic approach of this study produced a rich dataset and aligns with a tailored intervention to improving adherence and with a patient-centred approach.

Declarations
Author Information

Contributions
Data collection: HP. Data analysis: H.P., P.D. Manuscript writing: H.P., P.D. All authors contributed to study conception and design, critical review of manuscript for intellectual content, and read and approved the nal manuscript.

Corresponding Author
Correspondence to HP.

Additional Information
Funding This work was supported by a studentship from the Berkshire Masonic Charity and University of Reading.