ORIGINAL ARTICLE

Motivational interviewing to explore culturally and linguistically diverse people’s comorbidity medication self-efficacy Allison Williams, Elizabeth Manias, Wendy Cross and Kim Crawford

Aims and objectives. To examine the perceptions of a group of culturally and linguistically diverse participants with the comorbidities of diabetes, chronic kidney disease and cardiovascular disease to determine factors that influence their medication self-efficacy through the use of motivational interviewing. Background. These comorbidities are a global public health problem and their self-management is more difficult for culturally and linguistically diverse populations living in English-speaking communities. Few interventions have been tested in culturally and linguistically diverse people to improve their medication self-efficacy. Design. A series of motivational interviewing telephone calls were conducted in the intervention arm of a randomised controlled trial using interpreter services. Methods. Patients with these comorbidities aged ≥18 years of age whose preference it was to speak Greek, Italian or Vietnamese were recruited from nephrology outpatient clinics of two Australian metropolitan hospitals in 2009. Results. The average age of the 26 participants was 735 years. The fortnightly calls averaged 95 minutes. Thematic analysis revealed three core themes which were attitudes towards medication, having to take medication and impediments to chronic illness medication self-efficacy. A lack of knowledge about medications impeded confidence necessary for optimal disease self-management. Participants had limited access to resources to help them understand their medications. Conclusion. This work has highlighted communication gaps and barriers affecting medication self-efficacy in this group. Culturally sensitive interventions are required to ensure people of culturally and linguistically diverse backgrounds have the appropriate skills to self-manage their complex medical conditions. Relevance to clinical practice. Helping people to take their medications as prescribed is a key role for nurses to serve and protect the well-being of our increasingly multicultural communities. The use of interpreters in motivational

Authors: Allison Williams, PhD, RN, Associate Professor, Campus Head, Peninsula Campus School of Nursing and Midwifery, Monash University Health Sciences, Frankston; Elizabeth Manias, PhD, RN, Professor, School of Health Sciences, The University of Melbourne, Carlton; Wendy Cross, PhD, RN, Professor, Head of Nursing and Midwifery, Monash University, Clayton; Kim Crawford, PhD, Research Fellow, Peninsula Campus School of

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1269–1279, doi: 10.1111/jocn.12700

What does this paper contribute to the wider global clinical community?

• Migration patterns have seen cul-





• •

turally and linguistically diverse (CALD) people moving to predominantly English-speaking countries. The study has highlighted the complexity of issues facing CALD participants as they attempted to self-manage their medications for commonly occurring comorbidities. Participants’ inadequate English and lack of medication information available in their own language interfered with medication self-efficacy. Including culturally and linguistically diverse groups in research helps reduce health inequities. Using interpreters in research requires careful planning and adequate resources.

Nursing and Midwifery, Monash University Health Sciences, Frankston, Vic., Australia Correspondence: Allison Williams, Associate Professor, Campus Head, Peninsula Campus School of Nursing and Midwifery, Monash University Health Sciences, PO Box 527, Frankston, Vic. 3199, Australia. Telephone: + 61 3 9904 4377. E-mail: [email protected]

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interviewing requires careful planning and adequate resources for optimal outcomes.

Key words: cardiovascular disease, chronic kidney disease, comorbidities, culturally and linguistically diverse groups, diabetes, medication, motivational interviewing, nursing, self-efficacy, self-management Accepted for publication: 23 August 2014

Introduction The comorbidities of diabetes, chronic kidney disease and cardiovascular disease are increasing in prevalence globally (Wolf 2013). Diabetes is the fastest growing epidemic in human history and is the most common cause of chronic kidney disease, and together these comorbidities are frequently accompanied by cardiovascular disease (Tong & Stevenson 2007, Moulton et al. 2013). These comorbidities share common risk factors, and together negatively affect health beyond the sum of each disease; quality of life is worse, healthcare expenditure is increased and mortality is higher (Tong & Stevenson 2007). For example, having at least two or more of these comorbidities caused death for 132% Australians in 2004 (Tong & Stevenson 2007). The self-management of comorbidities primarily entails taking medications as prescribed (Williams et al. 2007), which is far more complicated than taking medications for one chronic disease. Self-efficacy- the confidence to carry out prescribed treatments necessary for optimal outcomes (Bakris 2004) – is likely to be significantly diminished with each additional disease requiring medication. In particular, the development of self-efficacy to manage comorbidities through taking medications as prescribed is more difficult for culturally and linguistically diverse (CALD) populations with limited access to interpreter services to explain their medication regimens (Williams et al. 2008). Migration patterns have seen CALD people moving to live in predominantly English-speaking countries such as Australia, Canada, UK and the USA. From an Australian perspective, 29% of the population were born overseas where the most common languages spoken at home are Mandarin, Italian, Arabic, Cantonese, Greek and Vietnamese (Australian Bureau of Statistics 2010), highlighting the importance of focusing on this population.

Background Prescribed medications are a key component in treating the comorbidities of diabetes, chronic kidney disease and

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cardiovascular disease, delaying disease progression and preventing further disease. According to Johnson (2002) based on research exploring medication-taking in hypertensive patients (Johnson et al. 1999), fundamental concepts that contribute to intentional and unintentional medication adherence are: purposeful action, the degree to which individuals decide to adhere to their medication regimen based on perceived need, effectiveness and safety; patterned behaviour, the degree to which people initiate and establish a behavioural routine of taking their medications; and feedback, the degree to which information, cues or events reinforce adherence or modify medication-taking. Research has shown that people of CALD backgrounds have lower medication adherence rates than those of non-CALD backgrounds. For example, a case–control study of 764 people with diabetes showed that black participants missed more medication doses, lacked knowledge about their medications and had difficulties enquiring about their medication problems when compared to white participants (Duru et al. 2009). Lower medication adherence rates in CALD people is chiefly attributed to health literacy issues, less access to healthcare services including the use of interpreters and time constraints involving health professional communication, and poor provider–patient relationship necessary for adherence to treatment (Manias & Williams 2010, Manias 2012). An Australian qualitative study using interviews to explore medication adherence in people with diabetes, chronic kidney disease and cardiovascular disease (n = 23), of which nine had CALD backgrounds, found this group in particular did not know what all their medications were for, were unclear about doses and the synergistic relationship of their diseases or how medications helped to control disease progression (Williams et al. 2008). A systematic review of interventions to improve medication adherence in CALD people found 20 studies with statistically significant improvements in medication adherence, six of which involved bilingual language support or the use of translated materials (Manias & Williams 2010). However, only 11 of the 20 studies © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1269–1279

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included 100% of CALD participants, and only three of these demonstrated improved adherence. Walker et al. (2005) examined chronic disease selfmanagement programs for Australian CALD populations including Vietnamese, Chinese, Greek and Italian people with varied chronic illnesses using focus group methodology (n = 24), finding that literacy was the major obstacle to chronic disease self-management. This work was extended in a randomised controlled trial testing a self-management program delivered to 320 CALD participants in their first language (466% had hypertension, 27% had diabetes and 13% had heart disease), finding significantly improved selfefficacy and general well-being at six months in the intervention group (Swerissen et al. 2006). While this study did not include motivational interviewing as part of the intervention, a meta-analysis of motivational interviewing indicates its extensive use in medical and psychiatric disorders, where nine studies of the 12 which met the inclusion criteria produced positive behavioural change (VanBuskirk & Wetherell 2013). Motivational interviewing is defined as, ‘a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence’ (Rollnick & Miller 1995, p. 326). This collaborative counselling technique adheres to the principles of avoiding argument, expressing empathy, developing discrepancy and supporting self-efficacy to facilitate behavioural change (Miller & Rollnick 2002). In summary, there has been little focus of past work on examining CALD people’s perspectives on medication adherence or how this group self-manages their comorbidities. Few interventions have been tested in CALD people to improve their medicine adherence (Haynes et al. 2008). The aim of this paper is to examine the perceptions of a group of CALD participants with comorbid diabetes, chronic kidney disease and cardiovascular disease to determine factors that influence their medication self-efficacy through the use of motivational interviewing using interpreter services. Involving interpreters in research requires careful planning to overcome obstacles such as a loss of control and spontaneity in interviews, misunderstandings and a lack of trust between the parties necessary for effective communication (Plumridge et al. 2012).

Methods Design A series of motivational interviewing telephone calls with people of CALD backgrounds with the comorbidities of diabetes, chronic kidney disease and cardiovascular disease in the intervention arm of a randomised controlled trial were © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1269–1279

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conducted using interpreter services. The randomised controlled trial using a multi-factorial intervention underpinned by the modified Health Belief Model (Glanz et al. 2002), which incorporated motivational interviewing has been reported elsewhere (Williams et al. 2010, Williams et al. 2012a). Motivational interviewing was considered appropriate to support the other components of the multifactorial intervention in the randomised controlled trial which included an individualised medication review and 20-minute PowerPoint presentation delivered in the participant’s preferred language to support optimal medication self-efficacy. The intervention was originally developed for English-speaking patients with these comorbidities which was then adapted for testing in this CALD group. The intervention nurse was trained in motivational interviewing and each interview question derived from the work of Dilorio et al. (2003) was read to the interpreter (Table 1). The interpreter then translated the question for the participant and then translated the participant’s response back into English to enable the intervention nurse to respond. The first call familiarised the participant with the interview schedule and established the pattern for the following calls. Participants were told that there were no right or wrong answers and to provide examples where possible to reduce the risk of reporting statements out of context and saying what they thought the interview nurse wanted to hear.

Table 1 Motivational interviewing schedule ● The script comprised sequential questions to provoke collaborative conversation, commencing with an openended question inquiring about the participant’s well-being. ● An enquiry about the participant’s medicines followed e.g. How are you going with your medicines? Prompts were used to facilitate conversation, such as, Have you had any problems with your medicines? ● Participants were then asked to score their motivation and confidence with taking all of their medicines as prescribed from 1–10, with a higher score being more favourable. ● This score was used to explore uncertainties about taking medicines using positive self-motivational statements to encourage self-efficacy. ● The participant was invited to suggest ways to improve their medication self-efficacy, and strategies that have worked for other people were proposed. ● Participants were asked to identify three life goals to expose any areas of ambivalence between these and their current behaviour. ● The call concluded with a summary of key points, affirmation of desirable behaviour, any queries and a request for the participant to try at least one strategy to enhance self-efficacy and positive behavioural change.

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Participants Patients with the combined diagnoses of diabetes, chronic kidney disease and cardiovascular disease aged ≥18 years of age recorded in their medical history who were mentally competent and whose preference it was to speak Greek, Italian or Vietnamese were recruited from the nephrology outpatient clinics of two Australian metropolitan hospitals in 2009. At the time of the study, approximately 40% of patients attending these clinics spoke languages other than English at home, most commonly Greek, Italian, or Vietnamese. A research assistant recruited 78 patients at the clinics with the assistance of a hospital interpreter or an Englishspeaking relative who attended the appointment with the patient. Participants had the plain language statement read aloud to them by the interpreter or family member and queries were answered with the assistance of the intervention nurse, prior to obtaining informed consent and prior to baseline data collection. Spoken English proficiency was measured by asking participants if they spoke English very well, well and not well or not at all (Australian Bureau of Statistics 1999) and mental competence was assessed as a score >6 using the translated Abbreviated Mental Test (Hodkinson 1972). Unfortunately, the attrition rate in this study was high, with 26 of 40 participants completing the intervention, and explanations for this have been previously reported (Williams et al. 2012b), mainly because of a lack of continuity of trained interpreters and communication difficulties.

Data collection An average of four motivational interviewing telephone calls were made fortnightly with participants (n = 26) in the 12-week intervention arm of a randomised controlled trial to support optimal medication self-management. A public on-call 24 hour Australia-wide interpreting service was engaged to provide translation services for non-English speaking participants with a member of the research team present at all times. Five participants reported that they spoke English sufficiently well as to not require an interpreter and three participants provided a family member who spoke English to perform translation. Interpreters received a short training session on how to conduct the interviews and were briefed by the interpreting service and by the intervention nurse prior to each call. A total of six Greek interpreters, eight Italian interpreters and two Vietnamese interpreters were employed over the course of motivational interviewing calls.

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The participants’ self-reported motivation and confidence in taking their medications was scored out of 1–10, using this information to elicit barriers, concerns and positive self-motivational statements. A score of 1 indicated the participant was not confident and lacked motivation to take their medications, while a score of 10 indicated the participant was confident and motivated.

Ethical considerations Prior to commencing recruitment, ethics approval from the hospitals and university was obtained from the human research ethics committees of the participating hospitals (HREC Project No: 2006.239 and HREC-A 061/08) and university (Ethics ID: 0713622). The study was conducted according to the protocol and under ethical guidelines of the National Health and Medical Research Council of Australia (2007). The intervention nurse advised participants on how to take their medications as prescribed, information which had been collected previously at enrolment to prepare the individualised medication review. The intervention nurse directed the participant to speak to their doctor regarding any questions that could not be clarified and to confirm any advice given that they were concerned about.

Data analysis All call notations were incorporated into the analysis. Data were analysed using a framework approach developed by Ritchie and Spencer (1994). This analytical approach has five key stages: first, familiarisation by intensive reading of the transcripts to list beginning themes and ideas followed by identifying a thematic framework consisting of themes and subthemes, indexing, charting and mapping and interpretation. Indexing involved a process whereby data were organised to link themes to the transcripts using NVIVO software (version 10, QSR International, Melbourne, Vic., Australia). Charting involved the organisation of transcript passages into themes and subthemes. Mapping and interpretation involved examining the analysis for congruence to produce a final interpretation of the complete data set. The data set and emerging analysis were examined by two independent members of the research team using NVIVO software (AW & KC) for consistency of meaning and agreement of the final analysis.

Results The demographic characteristics of the 26 participants are shown in Table 2. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1269–1279

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Table 2 Self-reported characteristics of participants (n = 26) Characteristic Male Country of birth Greece Italy Vietnam English proficiency level Not at all Not well Well Very well Sought General Practitioner of the same cultural background Spousal support provided Vision Not well Well Hearing Not well Well Regular exercise (30 minutes’ walk three times a week) Follow recommended diet Well Not well Not at all Age, mean (SD) Number of prescribed medicines mean (SD), (range) taken each day* How long diagnosed with diabetes, years, mean (SD) How long diagnosed with kidney disease, years, mean (SD) Number of other chronic illnesses, mean (SD)

n% 16 (615) 12 (461) 10 (385) 4 (154) 13 8 4 1 17

(500) (308) (154) (38) (654)

19 (73) 17 (654) 9 (346) 9 (346) 17 (654) 14 (538)

I have confirmation that I am doing the right thing in taking my 13 9 4 735 97

(500) (346) (154) (914) (427) (3–23)

196 (1187) 90 (1048) 35 (278)

*Insulin and over the counter medications were not included in this number.

Participants had lived in Australia for an average of 436 years (SD 1048), with the Vietnamese participants living in Australia the least amount of time, consistent with Australian immigration patterns. A majority of participants were retired (n = 22), and owned their home (n = 20). The highest level of education was primary school (n = 20). Most participants referred to having memory problems and wore glasses to correct their vision. Those participants who could not hear well reported using hearing aids ‘sometimes’. There were no obvious differences between participants with varying degrees of English proficiency in the data analysis. The fortnightly calls ranged from 3–23 minutes in length (average 95 minutes). Participants ranked their motivation and confidence to take their prescribed medicines between 1 and 10 on the first call only. One participant was unable © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1269–1279

to complete this task and three participants chose a higher number than 10. The term ‘motivation’ required explanation a number of times to some of the CALD participants in their preferred language. Participants’ self-reported motivation ranged from 5 to 11 (mean 875, median 10, mode 10) and their confidence in taking their medicines as prescribed ranged from 5–12 (mean 845, median 10, mode 10). One participant explained that, ‘Motivation 7/10. If I say 10/10, no good- got to have a bit of leeway- don’t want to set myself up’ (Participant 20). Participants were appreciative of the motivational interviewing telephone calls, reporting that the study was very useful, they were taught things they did not know, it helped to remind them to take their medications and they were disappointed when the phone calls were due to stop, requesting that the intervention nurse continue calling them. Overall, participants reported an improvement in their medication self-efficacy as a result of motivational interviewing. One participant found that the information he received reinforced that he was taking his medications correctly:

medicine. Thank you so much. It’s valuable. (Participant 20)

Data were coded into a total of 38 nodes and after careful inspection by two independent researchers, the nodes were reduced to 12 subthemes that were then organised into three core themes, which are presented in Table 3.

Attitudes towards medication Appreciates medication Participants spoke of the importance of taking their medications and recognised the consequences if they forgot to take their medication. A participant stated: Know I have multiple conditions and take them (medicines) as prescribed. Some medicines bad for you but not taking them is worse. (Participant 52)

One participant prioritised which tablet he took according to perceived importance, stating he always took blood pressure and diabetes medication (Participant 72). Burden of having to take medication This subtheme described the burden that participants felt, having to take their medication regularly. Participants reported the difficulty of keeping track of their changing medication and the burden of increased doses, for example: I’m on a different scheme, tablet for sugar increased every week; started with one, now two, and now three. (Participant 26)

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Some reported that their medications were restrictive to their social life or prevented them from functioning normally, affecting medication adherence. A participant stated: It’s not that I forget, taking medicines since 1978 but when I have visitors/friends, I deliberately do not take them. Alcohol and medicine are like dogs and cats and don’t mix. (Participant 33)

Participants were disheartened by the knowledge that they must always take their medication for the rest of their lives. Distrust of medications Over half of the participants spoke about a distrust of their medications (n = 14). Four participants questioned the effectiveness of their medication, for example:

participants (n = 6) reported that they used a dose administration aid such as a Dosette box. For some, it was important to maintain a routine; always taking their medications after a meal, filling scripts on the day they received their pension or keeping their medications in the same place. Most participants were unable to read or understand any English and found it difficult if not impossible to determine the purpose of each medication in the information leaflet provided with each prescription, although illustrations on medication packaging was helpful. One participant explained: I take tablets at 8 am every day; wake up, check blood sugar levels, breakfast then medicines. Some medicine boxes have pictures on them- heart, gut. (Participant 3)

My medicines seem to be no good anymore; I need to change them all the time. (Participant 26)

Participants reported that they were concerned about the number of medications they were required to take but stated they continued to follow doctor’s orders, for example: Taking so many (medicines) worries me but I do it anyway. (Participant 33)

Forgets to take medication Eleven participants reported that they forgot to take their medication at the prescribed time, particularly if there were additional instructions on how to take the medication. A participant explained: Doctor told me to take straight after food, wait ten minutes and sometimes 1–2 hours late as I forget. (Participant 34)

Concerned about side effects of medication Participants explained that they experienced different side effects from certain medications (n = 12) and feared dependence, as explained:

Some participants failed to see the importance of taking their medication close to the recommended time, even with medications that had a high risk of causing significant patient harm or death when used in error. A participant stated:

Sometimes I am very anxious – angry and I cannot sleep. The doc-

Sometimes warfarin late; one hour late as is only human. (Partici-

tor gave me some medicine for this problem but because of burning

pant 31)

sensation in tummy (stomach), not willing to take and don’t want to become dependent. (Participant 36)

Another participant told the intervention nurse that he believed his osteoporosis medication was causing him an upset stomach. He said: With my meds- 95% good – 5% upset stomach. Today I took a lot of meds. Two arthritis pills (alendronate) and stomach a bit upset. (Participant 72)

The participant was advised to speak to his doctor, and there could be an alternative medication. On the fourth motivational interviewing call, the participant said he ceased taking this medication altogether without consulting his doctor.

Having to take medication Behaviour that assists medication taking This theme related to strategies that the participants used to ensure they remembered to take their medications. A few

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Participants were sometimes reluctant to admit they were nonadherent; there was an instance when the intervention nurse suspected the participant was not telling the truth by

Table 3 Core themes and subthemes of the analysis Core Themes

Subthemes

Theme 1 Attitudes towards medication

Appreciates medication Burden of having to take medication Distrust of medications Concerned about side effects of medication Behaviour that assists medication taking Forgets to take medication Family support helpful Hoping not to become worse Insufficient knowledge of medication Blind faith in medical advice Medications are overwhelming Cost of medication

Theme 2 Having to take medication Theme 3 Impediments to chronic illness medication self-efficacy

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the change in tone of their voice. On another occasion, a family member admitted on behalf of their relative that they often forgot to take their medication; the participant denied this and quickly changed the subject. Family support helpful Eleven participants said that other family members, a spouse or child or grandchild that lived with them, assisted them by either preparing their medications for them, accompanying their relative to the doctor’s appointment and assisting with translation or acting as a personal reminder system. However, this method was not infallible, where even when using the Dosette box, both husband and wife ‘forgot pills this morning’ (Participant 65). One participant allowed his wife to take total control over his medications where he said: Wife ensures I take meds (medicines) every day. (Participant 73)

This participant relied on his wife to organise the dosages and put the medication out for him because he did not know the names of his medications or their intended purpose. In the absence of an able spouse, participants’ children assisted them with their medication taking. A participant (Participant 33) who realised how complex all his medications were asked his daughter to draw up a medications list for his reference, while another participant stated: Has so many pills I get daughter to refill (medicine prescriptions). (Participant 34)

However, some participants had traditional roles caring for the family which interfered with their self-care. A Greek participant stated: I have three (grown) men to look after and it influences my medicine taking. (Participant 36)

Other participants cared for sick family members which was an added stress, and prioritised their care over their own at times. A participant stated: Carer for parents. Blood pressure up to 240 [mmHg] systolic- ‘stressful’- and father has tumour of the liver. I put out tablets for parents and myself. . . I give pills to Mum. Sometimes Mum forgets she has already had them so I keep them in my room. (Participant 11)

Hoping not to become worse Participants were asked about their life goals, where many reported that their only hope was not to become sicker than what they already were. They used this as motivation for taking their medications, as explained: © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1269–1279

Medication self-efficacy in migrants Main goal that disease doesn’t progress and things will go well for me. (Participant 18)

Twelve participants experienced moderate to severe pain which required analgesia that risked further deterioration in renal function. A participant stated: Not too good today- knee is very painful- on Indocid (indomethacin), Endone (oxycodone) and Panamax (paracetamol and codeine). (Participant 20)

Impediments to chronic illness medication self-efficacy Insufficient knowledge of medication Participants lacked knowledge about their medications, not knowing what they were for, but claimed to take them anyway. One participant who spoke English adequately stated: I have to ring up chemist to check what pills are for – Pramin (metoclopramide

hydrochloride),

Urex

(furosemide),

Coloxyl

(ducosate sodium), Ostelin (vitamin D) as I often forget their purpose. (Participant 33)

One participant thought a tablet was for his heart but the intervention nurse informed him that is was an antacid. Another participant (Participant 45) was unsure of his medications for his diabetes so he took one of each (Glucohexal and Formet, which were both metformin). The intervention nurse explained these medications were the same and to check the dose with his doctor. Medication aids such as Dosette boxes limited the opportunity for participants to know which medication was which, as the original medication container as a point of reference was gone. A participant stated: Been given new tabs (hypoglycaemic agents) to replace other ones. Does not know what they are- chemist fills Dosette box. (Participant 26)

Additionally, with medication administration delivered in this way, if a tablet is dropped and cannot be located, there is no replacement (Participant 26). Pharmacists were noted to provide more information than the doctor, by ‘breaking things down to explain’ (Participant 31). However, the pharmacist support hotline, a telephone service providing individuals with information on prescription and over-the-counter medications, did not cater for non-English speaking people (Participant 30). Specialist letters for participants to give to their local doctor were also written in English and unable to be understood by non-English speaking participants. Additionally, knowledge of medications was noted to be impeded by short clinic appointment times, where a Greek participant stated:

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Blind faith in medical advice The majority of participants relied on their doctor’s advice; their doctor told them what to take and they dutifully followed orders. A participant stated: Does what doctor tells me to do. I really don’t want to take medicines but doctor tells me I have to. (Participant 51)

Most participants sought out a doctor who spoke their language (n = 17) or their English-speaking children called the doctor to clarify concerns. Whatever the case, participants believed their doctor’s advice without having the understanding to question that advice. Medications are overwhelming Taking multiple medications overwhelmed participants. To overcome these feelings, some participants attempted to normalise their life, reassuring themselves that despite being dependent on medication, they were just like everyone else: Don’t think you are sick, think normal- I take tablet- same as other people. If you think that way, you die quicker. (Participant 77)

Some participants ceased monitoring their blood glucose or taking their medication, using alternative methods to have some perceived control over their well-being, as explained by an Italian participant: Lasix (frusemide) 40 mg daily – ‘I don’t take anymore. I didn’t take- drink green tea at night for urine output instead’. (Participant 33)

Cost of medication Three participants spoke about the cost of their medication, where they were reluctant to fill their prescriptions because they were expensive and ‘everything costs so much’ (Participant 78). Seven participants reported the benefits of the Australian Pharmaceutical Benefits Scheme ‘safety net’; under this scheme the Australian Government subsidises the cost of listed prescription medications and once the individual reaches the predetermined Safety Net Threshold, prescription medication becomes significantly cheaper or at no cost.

Discussion These CALD participants’ perceptions highlighted the complexity of issues they faced in self-managing their

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medications. Although participants were aware they needed their medications, insufficient or misunderstood knowledge about their medications gave the participants little control over their well-being, impeding confidence necessary for optimal disease self-management. Health literacy is a key obstacle negatively affecting self-efficacy in disease self-management as reported in CALD groups by Walker et al. (2005), Duru et al.(2009), Manias and Williams (2010), and Manias (2012). Yet participants’ selfreported motivation and confidence to take their medications was high, similar to non-CALD participants with these comorbid conditions requiring multiple prescribed medications (Williams & Manias, 2013). This may reflect the bias inherent in self-report, wanting to avoid conflict and in the case of CALD participants and not wanting to jeopardise access to available health services in the country they had migrated to. Participants prioritised which medications they thought were the most important to take while others substituted herbal remedies to take less medication and have some sense of control over their health. Of Johnson’s (2002) model of medication adherence, patterned behaviour incorporating routine, family support and dose administration aids, was the strongest concept in the analysis affecting medication self-efficacy in this CALD group. Alternatively, the concept of purposeful action based on need, effectiveness and safety of medications and the concept of feedback were less commonly referred to. Participants’ inadequate English and the lack of medication information available in their own language interfered with medication self-efficacy. Barriers to medication self-efficacy found in the present study were consistent with those found in prior studies. In the present study, participants were reluctant to admit they were nonadherent but on the occasions they did, developing discrepancy to facilitate behavioural change using an interpreter or family member in the motivational interviewing calls was more difficult. Participants admitted to forgetting to take their medication, which may relate to denial as a method of coping with the anxieties associated with complex and overwhelming health problems affecting medicine adherence (Williams et al. 2009). Participants were required to take multiple medications that were prone to prescription changes. In some cases, the responsibility for the medications was delegated to a relative or pharmacist by way of a Dosette box. While Dosette boxes simplify medication taking, tablets are removed from their original packaging into compartments by day and time, where even the most literate CALD participants were at risk of having insufficient knowledge © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1269–1279

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about their medications. Participants encountered further obstacles because medication education was usually provided in English, increasing the communication gap between health professionals and CALD participants. In most instances, participants followed their health professional’s orders, without having the understanding to question that advice. Participants saw medications as a costly burden that interfered with their lifestyle; yet, they felt compelled to take their medications to maintain their current health status. Participants were a group of older people with minimal formal education and had limited opportunities and resources to support their medication self-efficacy. These participants found it stressful managing their multiple medications and valued the individualised calls and having the freedom to ask questions about their health out of the constraints of a formal medical appointment. A lack of formal education and high stress levels has been reported to correspond to lower medication self-efficacy (Reynolds et al. 2004). Health professionals have an ethical responsibility to facilitate CALD groups’ active engagement and motivation in managing their health. Healthcare systems tend to offer limited support to help CALD groups manage increasingly complex diseases independently. Interpreting services were available in the hospital setting although there were few support services available in the community for this CALD group. Participants often sought out the services of bilingual health professionals to help them understand basic information about their medications. In the absence of educational programs to ensure all CALD populations have sufficient English for optimal self-management, the importance of ensuring adequate understanding and partnership between the doctor and patient can be facilitated by matching patients with doctors of the same culture and language (Manias & Williams 2010). Other strategies to improve medication self-efficacy in CALD groups include regular medicine reviews and longer consultation times with interpreters. Our findings resonate with previous research investigating self-management skills in CALD groups in Melbourne, Australia. Walker et al.(2005) used focus group methodology facilitated by interpreters to highlight health literacy as an impediment to implementing the Stanford chronic disease self-management program (CDSMP). This program was specifically designed for educated, self-determined English-speaking people (Lorig & Holman 1993). Swerissen et al. (2006) tested the CDSMP in a randomised controlled trial in Vietnamese, Chinese, Italian and Greek participants where participants reported improved well-being but © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1269–1279

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no change in healthcare use. As with our study, cultural differences were evident between the groups and the high withdrawal rate may indicate insufficient health literacy to build on and a reluctance to learn complex material concerning disease self-management. Nevertheless, the findings of our study have contributed to the knowledge of medication self-management in CALD groups using a personalised approach.

Limitations Using telephones to conduct motivational interviewing and not audio recording each motivational interviewing call are major limitations of the study. However, this is a subanalysis of a larger study and transcribing each call of the intervention was not considered due to time and funding constraints. The intervention nurse took ad verbatim handwritten notes during each call to capture what participants said to inform the following calls. The annotations included short sentences and phrases comprising approximately 17,500 words which was considered valuable and worthy of reporting. The availability of on-call interpreting services at the time of the study meant that continuity of qualified interpreters to allow for increased familiarity and trust to develop necessary for motivational interviewing was limited. Moreover, an interpreter introduces a third person into the motivational interviewing relationship, making it difficult to gain immediate, spontaneous and meaningful responses (Plumridge et al. 2012). In addition, the intervention nurse who only spoke English was unable to confirm non-English conversations between the participant, family and interpreter. Barnes et al. (2011) found that less content is covered with the use of interpreters who may use a didactic rather than a motivational style in intervention delivery (Barnes et al. 2011). These issues undoubtedly contributed to the high attrition rate. The potential interference of the family member as interpreter also cannot be overlooked. Employing a bilingual intervention nurse would help reduce the to- and- fro of translated replies and increase the efficiency of the calls. Alternatively, peer-led group support sessions and language applications for mobile phones require development and testing for efficient ways of supporting medication self-management in CALD groups. Motivational interviewing requires sufficient health literacy for success and this approach may have been inappropriate for this group of participants. However, an average of four motivational interviewing telephone calls was made to each participant, and the approach was repetitive and personalised.

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Conclusion

Disclosure

The findings of this study report the diverse perspectives of a group of CALD participants grappling with the complexity of managing multiple prescribed medications. Communication gaps affecting medication self-efficacy were highlighted. Participants’ inadequate English and lack of medication information available in their own language interfered with medication self-efficacy. Culturally sensitive interventions are required to ensure people of CALD backgrounds have the appropriate skills and resources to selfmanage their complex medical conditions.

The authors confirmed that all authors met the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author. html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be published.

Funding This research was supported by the 2008 Mona Menzies Nurses Board of Victoria Grant and a 2009 Amgen/Renal Society of Australasia Career Mobility Sponsorship.

Relevance to clinical practice Global migration patterns make it imperative to include CALD people in research. Helping people to take their medications as prescribed is a key role for nurses to serve and protect the well-being of multicultural communities. Using interpreters in research requires careful planning and appropriate resources.

Conflict of interest No conflict of interest is declared.

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Motivational interviewing to explore culturally and linguistically diverse people's comorbidity medication self-efficacy.

To examine the perceptions of a group of culturally and linguistically diverse participants with the comorbidities of diabetes, chronic kidney disease...
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