The study included participants who were authorised to prescribe, with 2 years of working experience in the two selected hospitals. The researcher recruited the participants by conducting several meetings and presented the study proposal. Prescribers included community service doctors, medical officers, specialists and consultants. These prescribers are an ideal target in the study as they play a key role in the prescribing and initiation of polypharmacy and, as such, bear significant responsibility in deprescribing. Purposive non-random sampling was used to gain an in-depth understanding from 13 authorised prescribers. Individual face-to-face, in-depth, semi-structured interviews were used to collect data from 13 participants.

The researcher was responsible for data collection by conducting individual semi-structured interviews. The interviews were conducted in English in a private, designated, noise-free room from August to October 2023 and lasted for 30 to 103 min. The interview guide was used to obtain data from the participants. Three focal questions were used during the interview: ‘What are your views regarding deprescribing as a tool to avert polypharmacy?’; ‘According to your observation, what are the factors that contribute to polypharmacy?’ and ‘What do you think can be done to enhance deprescribing of polypharmacy?’ Extra probing questions were asked to gather a deeper understanding of polypharmacy. The interviews were captured by the researcher with the use of an audio recorder with the permission of the participants. Field notes were documented by the researcher in order to capture the nonverbal cues displayed by the participants. The interviews continued until data saturation was reached at participant number 13, when additional data no longer yielded new insights. Data collected by the researcher was transcribed verbatim, then submitted to the independent co-coder to confirm and enhance the trustworthiness of the results.

Data were analysed manually, using Tesch’s eight steps of qualitative data analysis as outlined in Cresswell and Cresswell (2018) and Makua and Khunou (2022). The researcher commenced by reading the entire transcripts in order to get an understanding of the underlying meaning. Individual transcripts were read to gain insight into the developing subtopics, which were then recorded in the document margin. Broad topics were outlined and summarised with codes that were duly outlined in relevant areas. In step number five, descriptive words were aligned with the identified topics and categorised into groups. The categories were then summarised and named appropriately to avoid repetition. The last step included documentation to get the comprehensive meaning and general sense of the data.

Validation of data was carried out by a qualified co-coder who was outsourced to independently code the qualitative data using the provided protocols. Both the researcher and the co-coder arrived at an agreement for the good and purpose of achieving conformability and thereby enhancing trustworthiness. Probing, clarifying and paraphrasing techniques were employed to allow free expression until data saturation was reached. Field notes were documented, and audio recordings were used to capture the data, which was transcribed verbatim. Credibility was achieved by meaningfully engaging with the participants. The researcher established a positive rapport and encouraged free engagement. Verification permitted participants to rectify errors and volunteer additional information. Following the transcription process, the researcher presented the transcribed notes to the participants. To achieve dependability, care was taken to ensure that the study methods were verifiable, logical and explicitly documented in a succinct manner by giving a detailed description of the study methods.

The study obtained ethical clearance from UNISA’s Higher Degree Ethics Committee (Reference number: REC-248016-052). Permissions were also obtained from the Department of Health Johannesburg Health District and Ekurhuleni Health District Research Committees (Reference number: 202308-004). The researcher adhered to confidentiality and respect for the participants’ rights. The researcher signed a confidentiality form, which bound them to comply with and adhere to privacy and confidentiality clauses pertaining to qualitative research. The researcher adhered to principles of respect, beneficence and justice throughout the study (Polit & Beck 2017).

The study revealed the negative impacts of polypharmacy as addressed under the following emergent sub-themes, namely: (1) the negative impact on the patients, (2) the impact on prescribers and (3) the impact on the organisation.

The factors that discourage the deprescribing of polypharmacy were the second theme that emerged. This theme gave rise to four sub-themes: (1) prescriber-related factors, (2) patient-related factors, (3) complexity of the prescribing environment and (4) deficiencies in organisations.

The prescribers recommended remedial and preventative measures to avert polypharmacy. This theme led to the development of two distinct categories: (1) holistic systems for the deprescribing of polypharmacy and (2) promotion of awareness and education.

The prescribers described that polypharmacy has a negative impact on the patients, prescribers and the organisation. It is clear that the aftermath of polypharmacy on patients includes drug abuse and adverse drug effects. In most cases, prescribers found an addiction to antipsychotic drugs among other prescribed medications. The study’s findings were in agreement with a study by Singier et al. (2021) who articulate that misuse of drug is unwarranted if it does not comply with regulatory and medical guidelines. Furthermore, drug misuse and abuse are linked to increased risk of adverse reactions, addiction and fatal overdose. In addition, Karakaş et al. (2019) also confirmed that medicine exploitation, addiction and misuse are common in day-to-day medical practice. The participants admitted to having difficulties distinguishing between medical ailments and symptoms because of the side effects of medications. According to WHO (2019), an ADR is a harmful and unexpected response to a medicine, occurring at doses typically used for diagnosis, disease therapy, prophylaxis or modification of physiological functions. In this study, it was outlined that an increase in ADRs resulted in additional demand for healthcare utilisation. To corroborate, Osanlou et al. (2022) explore adverse drug reactions, multimorbidity and polypharmacy, highlighted that there were 218 identified patient admissions with an ADR giving a prevalence of 18.4%. To support, Pereira, Veríssimo and Ribeiro (2024) assert that there exists a direct correlation between polypharmacy and increased adverse drug reactions.

Because of polypharmacy, prescribers bored the brunt of work pressures as a result of polypharmacy. In this aspect, the prescribers had to spend most time dealing with the effects of polypharmacy, be it the ADR or misuse and addiction of drugs. In the same breath, the health organisation had to spend a huge amount of money in dealing with polypharmacy. In this regard, prescribers attributed the need for more healthcare resources in order to manage polypharmacy. As a remedial action, Akande-Sholabi, Ajilore and Ilori (2023) submit that adequate resources should be availed in order to avert ADRs through judicious deprescribing. This may demonstrate that prescribers have proactive attitudes and the intention to alleviate negative effects of drugs.

This section addresses objective two of the study, which deals with experiences of prescribers regarding deprescribing of polypharmacy. Prescribers cited a negative attitude towards deprescribing because practitioners do not want to upset patients by removing some of the medications from their long list. This was in line with Giménez et al. (2020) who explored prescriber’s attitudes and beliefs about polypharmacy and found that there are positive attitudes, and some prescribers do in fact make deliberate efforts to reduce polypharmacy. In addition, this can be attributed to the lack of confidence and knowledge about medications and guidelines. Thus, the experience of prescribers’ reveals apathy, demotivation, discouragement and fear to deprescribe, which are all negative attributes. The lack of pharmacological knowledge was also alluded to in the study. The participants indicated that their prescribing tendencies are informed by what is done in the system by their seniors. It is interesting to note that people who are supposed to be knowledgeable about prescribing medicines are not proficient or well acquainted with the pharmacology of medicines. To corroborate, Mahomedradja et al. (2023) postulate that prescribing errors occur in 7% of total medication orders and up to 50% of hospital admissions.

Prescribers also pointed out several organisational barriers that hindered the deprescribing of polypharmacy. The absence of deprescribing guidelines and protocols significantly hinder the process of deprescribing. This underpinned by a study by Bashkin et al. (2022) highlighting that doctors explained that prevalent lack of expertise and proficiency points to an urgent need for upscaling of skills to deal with difficulties such as deprescribing polypharmacy. Furthermore, Davila et al. (2022) advise that refining admittance to easy technologies as tools for deprescribing will aid the process.

Most participants gave accounts of how busy the hospitals and clinics are, and that most prescribers are overworked, making it difficult to include deprescribing into a consultation. Some participants expressed concerns about the absence of beneficial treatment alternatives that could prevent polypharmacy. To corroborate this, prescribers expressed that the diversity of prescribers, each with their own philosophy regarding medication prescribing, presents a significant challenge on deciding the prescriber supports medication discontinuation or not. The prescribers stressed that patients resist the suggestion to take less medication. In their minds, more medication means better health; when they have become accustomed to taking a lot, they are not keen to change.

Participants expressed the need for a holistic system to deprescribe polypharmacy through inculcation of guidelines, SOPs, creating awareness and education at both prescriber and patient level. To fortify, Anderson et al. (2024) confirm that most systemic impediments can be attributed to a lack of information on a patient’s full medical records and previous diagnoses, prognosis indications and medicinal regimen. It is important for prescribers to know when and how to up-refer and down-refer a patient. Participants expressed the importance of raising awareness and educating prescribers about the concept of deprescribing. A resounding agreement by majority of participants emphasised the crucial role of patient education and counselling to encourage patients to consider deprescribing polypharmacy as a viable option.

Participants expressed that although their medical training might have been reasonably good, it did not put emphasis on pharmacology and pharmaceutics as important subjects but rather focussed on diagnosing and examining practice and technique. To corroborate, Trani et al. (2024) suggest that enhancing educational programme should include the following: elicit patients’ specific needs prior to intervention and delivery, facilitating the provision of concise summaries and key messages, implementing regular follow-ups with participant’s post-intervention and incorporating family members into educational sessions.

In that regard, it was addressed that despite the existence of several evidence-based deprescribing tools and guidelines, the limited awareness highlights the need for further training and sensitisation to enhance knowledge and equip doctors with the much-needed skills to deal with the existing demands of modern-day multimorbidities. Findings by Akande-Sholabi et al. (2023) affirm that there is a dearth of knowledge on deprescribing tools and guidelines, and this needs to be rectified. In addition, medical education offered by university medical schools should make a concerted effort to inculcate deprescribing of polypharmacy as part of a learning objective. Furthermore, Omer et al. (2021) advises that it is crucial for medical students to improve their theoretical knowledge alongside the development of necessary skills and attitudes for safe prescribing within an interactive clinical context.

Enhance drug information services by establishing a mechanism for medication error identification and reporting. Interventions targeting professional development, better collaboration structures with laboratories and clearer and more user-friendly guidelines could potentially support rational antibiotic prescribing behaviour. In addition, better networking and social support among physicians could support lower prescription rates. Improved knowledge on deprescribing and inclusion as a subject matter for continuous professional development. Research must be conducted to develop the deprescribing instruments specifically designed for public hospitals. More researches are required to establish the level of adherence to prescribing and deprescribing guidelines. It would also assist in investigating prescribers’ knowledge and confidence in deprescribing guidelines. An exploration of prescriber-related factors influencing deprescribing within a multidisciplinary team.