Decision-making evolution and two-way concealment in active self-reduction of medication among older adults with multimorbidity and polypharmacy: a qualitative study

Abstract Background Older adults with multimorbidity and polypharmacy sometimes reduce their prescribed medicines without professional authorisation, yet the hidden decision process behind this active self-reduction, and how patients simultaneously manage information towards clinicians and family, remain poorly understood, particularly in family-care settings. This study explored how older adults in China initiate, trial and conceal active self-reduction in order to inform patient-oriented, out-of-hospital medication-safety nursing. Methods A descriptive phenomenological qualitative study was conducted. Between January and March 2026, maximum-variation purposive sampling recruited 15 older adults with multimorbidity and polypharmacy from a tertiary hospital geriatric outpatient clinic and a community health service centre in eastern China. Face-to-face, semi-structured interviews (30–45 minutes) were analysed using Colaizzi’s seven-step method, sensitised by the common-sense model of self-regulation and communication privacy management theory. Reporting follows the COREQ checklist. Results Three themes and nine sub-themes emerged: decision triggers (somatic symptoms and adverse reactions; traditional medication beliefs amplified by online information; cost and access constraints); the practice process and information management (reversible trials and trajectory divergence; two-way concealment from clinicians and family; reconciling perceived benefit with guilt); and medication-support needs (individualised guidance, non-judgemental communication and continuous primary care). Self-reduction followed a trigger–weighing–trial–judgement–divergence trajectory that ended in a retreat, oscillating or entrenched pattern. Two-way concealment created a dual blind spot for clinicians and families. Conclusions Active self-reduction is intentional self-regulation shaped by bodily perception, culturally rooted beliefs, economic burden and healthcare accessibility rather than simple non-adherence. Out-of-hospital medication nursing should shift from adherence supervision to supported self-regulation, extending nurse-led medication reconciliation and non-judgemental, continuous care into the community and engaging family caregivers.