Aunque se vive individualmente, la experiencia con la medicación es colectiva y requiere un enfoque relacional para realizar prácticas clínicas contextualizadas.

The expression “medication experience” (MedEx) has emerged in the context of Comprehensive Medication Management (CMM). The term was first coined by Cipolle et al.1–3 as the lived experience of patients with their medications, which shapes their attitudes, beliefs, and preferences in relation to medication and determines their behavior when taking medication. To develop this concept, the same authors1 resorted to terms from the field of medical anthropology, such as illness narratives described by Kleinman.4 This expression explains how patients express and understand illness. The authors also consider the link described by Brown et al.5 between behavior and illness experience, i.e., the experience of being ill. Thus, the authors translated these concepts into pharmaceutical care and examined whether ideas about disease, feelings, and clinician's expectations, along with the effects of disease on patient's functionality may directly influence MedExp. As stated by Good,6 “the experience, suffering, distress, and perils that threat people” are a subject of study of medical anthropology. Thus, qualitative studies are conducted on “human experience and the existential ground of culture” take theoretic frameworks from social sciences “to comparatively analyze disease and healthcare practices”, including CMM. Based on this humanistic approach, Cipolle et al.1,2 argue that patients have stories to tell health professionals, who can learn much from patients. Narratives are a major source of information that should be the core of pharmacotherapy history and could be used to design pharmacy care plans.6,7

Qualitative studies consider that experience is communicated in the language of culture, patient's symptoms are coded in cultural language and the “primary interpretative task of the clinician is to decode patient's symbolic expressions”.6 According to these 2 approaches, understanding MedExp will help incorporate into CMM practices the bodily phenomena linked to sociocultural phenomena that patients experience when their illnesses are treated with medications. This approach will help professionals adopt a holistic strategy for the development of personalized solutions to pharmacotherapy-related problems. In clinical pharmacy practice, Shoemaker et al.8 and Ramalho-de-Oliveira et al.9 recognize the relationship between MedExp and pharmacotherapy problems. MedExp has also been analyzed from a phenomenological perspective6,10,11 based on existential categories such as time, space, relationships with others, and sexuality, which are integral to the lived body.10,12 Silva-Castro13 considers that it is necessary that the pharmacist adopts this perspective. This way, the pharmacist will understand how patients make decisions when taking their medications, their actual behaviors, along with bodily, social, and political expressions concerning “the experiential dimension of human suffering”. The author states that it is necessary to contextualize each MedExp in patient's culture to obtain clinical outcomes that improve the health of people.14

When pharmacists engage in patient care through CMM, MedExp serves as a link, since it involves examining pharmacy interventions qualitatively, in terms of patient's beliefs, understanding of medication, preferences, concerns, and behaviors.15 Interestingly, the first principle proposed by the Royal Pharmaceutical Society to help patients make the most of medicines was Medicines Optimization.16 In the same line, Schommer et al.17 note that clinicians' perception of diagnosis, drug-therapy decision-making, and risk weighting may differ from patient's perceptions. Thus, the authors highlight the relevance of understanding patient's MedExp in their context to determine their preferences as to medications. Machuca18 adds that MedExp depends on patient's ability to process data and absorb information and on interaction with their sociocultural and political environment. When contextualizing the situation of a patient to improve their MedExp, Viana et al.19 remark that MedExp is crucial in decision-making, as it is often expressed as an understanding and concern regarding medication. Care should be taken not to judge the attended person when assessing their experience.

Now, we understand the relevance of adopting a humanistic approach in pharmacy practices through the analysis of medication experience. The aim of this review was to understand how the pharmacists who provide CMM services assess MedExp in their patients. We also analyzed the categories established in pharmaceutical interventions and how individual, psychological, and cultural dimensions of MedExp are explained. The objective of this study was to perform a review of the literature on MedExp and the related interventions that generate a change in the health of patients receiving pharmaceutical care.

This scoping review improves our understanding of how the idea of MedExp has evolved, as a key concept for pharmacists. The information obtained is useful, given the heterogeneity and complexity of the studies retrieved, selected, and analyzed. PRISMA guidelines were a valuable instrument20 in managing the heterogeneous categorization of MedExp and different types of pharmaceutical interventions implemented. In addition, PRISMA guidelines49 helped us to map the qualitative research techniques used and the results obtained on this broad emergent theme. To such purpose, pharmacists need to use qualitative health research methods that had not been used before in this field.

A limitation of this study is that studies published in languages other than English and Spanish were excluded, which prevented the analysis of MedExp in other sociocultural contexts. Although search was carried out on 4 databases, it may have been inaccurate, given that specific MeSH terms have not yet been established. Thus, the lack of standard keywords may have hindered retrieval of relevant articles due to indexation problems.

Another relevant aspect when performing a scoping review of qualitative research studies is that the aim was to understand what happens in the life of patients taking medications and their context. For this reason, it would have been useful to include qualitative studies that analyzed the progress of MedExp following the implementation of pharmaceutical interventions. When pharmacists get an insight into the symbolic world of the patient and decodify the meaning of medication users, they are able to understand, interpret50and analyze significant events6 to help patients change their medication experience. Access to this world is gained using qualitative research methods. Therefore, future studies should be focused on social practices to analyze what patients actually do and assess relationships between the stakeholders51 involved in patient care.

Regarding the quality of studies, some studies do not describe the research paradigm or theoretical frameworks used. This limitation hinders comparative analysis of contents, since the theoretical rationale for the qualitative analysis performed is not available. As a result of the influence of the biomedical model on CMM, sociocultural problems are not addressed. However, these factors, such as those that would emerge if cross-sectional or gender-based approaches were adopted, are most frequently included in biomedical research. This way, the exclusion from analysis of social determining factors or race-, gender-, or religion-based discrimination, along with other social phenomena affecting medication users, would not be reproduced.

Regarding the analysis of contents, Shoemaker et al.25 laid the foundations for the categorization of MedExp from a phenomenological perspective.22,24,25,30 Hence, categories are based on patient's perceived sensory experience and on the direct relationship between sensory perceptions and learning how to use medicines from the body scheme of each patient.11 This theory is related to the concept of embodiment.47,52 According to Esteban,44 this concept does not only refer to the biological body, but also understands the body as a “conscious, experiential, acting and interpreting entity”.

Other authors23,29,31,34,35,37,41,42,46 categorize MedExp from a social-constructivist53,54 and symbolic interactionism approach.55,56 From these sociological perspectives, the authors explore how patients build and implement what they understand about their medication in socially mediated contexts. Also, these studies reveal that ignoring that social life is built from interactions with others invalidate the individual meaning4,6 assigned to any experience that is interpreted from an individual rather than collective perspective. According to these analytical perspectives,57 experience is a human construct and patient actively takes part in this transformative process. From the social-constructivist and interaction perspective, MedExp cannot be separated from the social processes that compose it or from the context where it develops and evolves. The studies23,29,34,39,41,42 are based on this analytical perspective. Thus, they categorize MedExp as a journey, a dynamic process resulting from interaction with the environment, with special relevance given to the interrelation between MedExp and chronicity.58

The studies that use illness narrative59,60 on how patients use their medications to analyze MedExp focus discourses on individuality. However, although these studies are relevant, they may miss the information provided in the narratives of other stakeholders that interact with the patient, which will determine “the building of MedExp”, with the latter having a collective nature.61

Understanding and contextualizing MedExp may transform illness experience.22,23,29,34,38–40 Psychologists and specialists in social psychology affirm that listening to and reconstructing their own history62 is therapeutical for patients and creates a climate of empathy and trust.60 Some studies have assessed the influence of emotions.63 Thus, MedExp is determined by the psychological characteristics of medicine users, thereby conditioning self-perception of the worsening or improvement of their health.64,65 Good6 defines that the generation of narratives as an individual and social process that may help understand the impact of illness and medication on the life of the patient, and prevent its disappearance or deconstruction. According to the author, “narratives do not only describe the source of suffering, but also help understand its location and origin and find a solution”. Some pharmacists focus their interventions on the discourse of the patient and provide realistic solutions through contextualized pharmaceutical interventions. The studies included confirm the hypothesis of Menéndez66 that despite the high understanding of medication by patients, their personal experience often moves them to quit or use their medications differently to as prescribed. Some health professional could label their patients as “non-adherent” based on a value judgment that ignores the sociocultural determining factors that mediate that decision. However, as uncovered in studies,22,23,29,34,38–40 when a pharmacist takes the time to analyze patient's experience in more detail, they understand the cause and may provide a solution. By understanding MedExp, pharmacists learn about patient's reasons for non-adherence and identify the individual needs or barriers experienced by patients with a particular condition. The attempt to quantify adherence is based on the rationale of the prevailing biomedical model,66,67 which invalidates beliefs and reduces the psychosocial context of a patient to a numerical parameter. In this line, Martínez-Granados68 explain that pharmacists should consider whether they look at the other (the patient) from a position of equal power and mutual respect, where the patient is no imposed to obey an order, or from a perspective based on the understanding of the sociocultural meanings that determine their behaviors.

This review confirmed the influence of socioeconomic conditions in personal experiences.31,33–35,41 The World Health Organization69 defines as a fundamental right of every human being the right to health enjoyed without discrimination on the grounds of race, age, ethnicity, or any other factor. The WHO also highlights the need for states to take steps to redress any discriminatory law, practice, or policy. Finally, the organization establishes that the price of the medication and financial situation of each user of pharmacy services should always be considered when designing individual pharmaceutical interventions. Patients occasionally reduce dose or quit medication to save costs or because they are not subsidized by the public health system.

Considering narratives about beliefs, some studies23,25,31 associate discourses with the symbolic world of patients, consistently with Good's approach.6 This point of view dismisses beliefs as statements that others do about what they think (convictions), which transmit a value judgment to the investigator.36,42 The integration of beliefs has demonstrated that people have capacity of self-care, and knowledge bases its legitimacy on religion.66 Accordingly, patients' beliefs have been considered in some pharmaceutical interventions,35,39 including patient education on diseases and medications8 in contextualized healthcare practices where understanding the religious beliefs of patients was key when providing guidance to patients on their medications.35

With respect to education on medications and disease, studies29,32–36,38,41,42 consistently demonstrate that understanding MedExp helped develop individualized8 and collective34 patient education strategies. However, although education strategies may transform MedExp,2 some studies23,29,34,37,39 reveal that patients have a deep understanding of their disease and medication and develop self-care practices.66 On the basis of the evidence available, it would not be useful to undertake an educational campaign without first knowing the needs of the patient, without imposing biomedical knowledge, or excluding or denying discourses (a power relationship), when symmetrical relationships must be fostered.70 Thus, the patient's “clues” or “their presumptive self-diagnosis” should be first understood.66

The cultural interventions analyzed 22,23,29,31,33,34,40,42,46 reveal the advantages of integrating support networks, and involving relatives and community and patient associations to reduce cultural barriers in CMM. These studies confirm in practice what some authors61,71 warn about the fact that patient-centered practices may be insufficient if they do not involve contextualized practices in the community of the person who gets ill. Only this way pharmacists will be able to provide “contextualized care”.61

In the same line of Martínez-Hernáez,67 the reviewed studies22,23,32–35,37,41 suggest interventions that incorporate the dialogic model, symmetrical therapeutic relationships, and shared decision-making. This approach is based on the fact that the dialogic model is a bidirectional, multidimensional flow of information resulting from a reciprocal relationship of balanced interaction. This approach creates a connection between the health professional and the patient, based on the understanding of mutual knowledge, which helps them build together a new experience and serve as a basis for shared decision-making. With respect to building symmetrical therapeutic relationships, several studies23,32 identify trust as a predictive factor of intervention success.72

The interventions involving a comprehensive approach and timely referrals to other health professionals described in the studies23,24,33,34,36 adopt the biopsychosocial model. Thus, they suggest to analyze disease in the context of patient's life on the basis of their activities, feelings, and behaviors, rather than adopting the hegemonic biomedical model, which emphasizes the mind–body binomial.73,74 Pharmacists are aware of healthcare pluralism48 and that they are part of conventional care models. However, they are also surrounded by traditional, alternative, popular models, such as self-care.75 The latter involve relationships between communities/social subjects; therefore, they understand what living with medication actually involves and how people deal with their health problems in their everyday life. Using this approach, they have analyzed the effectiveness of interventions and optimized pharmacotherapy based on actual patient experiences. Therefore, pharmacists have adopted the vision of CMM as an integrative care practice. With this approach, they can determine whether to refer a patient or seek alliances with other health agents for the sake of the well-being of patients. When healthcare practices are considered as social facts, the relational approach66 is adopted, which enables to advance towards contextualized clinical practices.61,71

In the light of the findings of this scoping review, future research should broaden the definition of MedExp as the experience lived by a person who uses their medications according to their individual, psychological, and social qualities. Experience with medications is bodily, intentional, intersubjective, and relational and extend to the collective context, as it involves the beliefs, culture, ethics, and socioeconomic and political reality of each person in their context.

Although it is lived individually, medication experience is collective and requires a relational approach for clinical practices to be contextualized.

Understanding medication experience enables the provision of contextualized pharmaceutical interventions, thereby resulting in improved health outcomes.

None of the authors received additional support from internal or external entities. This scoping review was conducted as part of the PhD program of San Jorge University, therefore, it is the product of a scholar activity. No funding.