RESEARCH ARTICLE

Adolescents’ struggles with swallowing tablets: barriers, strategiesand learning

Dana Lee Hansen Æ Ditte Tulinius Æ Ebba Holme Hansen

Received: 9 January 2007 / Accepted: 1 June 2007 / Published online: 27 June 2007

� Springer Science+Business Media B.V. 2007

Abstract Objective To explore adolescents’ struggles

with taking oral medications. Setting Copenhagen, Den-

mark. Method Semi-structured qualitative interviews were

conducted with 89 adolescents (33 boys, 56 girls) between

the ages of 11 and 20. Adolescents were recruited through

four public schools. To identify struggles with taking oral

medication, interview transcripts were systematically

searched for statements including the terms swallow, chew,

crush and eat. Thematic analysis of the identified state-

ments was carried out to reveal dominant themes in the

adolescents’ accounts. Results Over one-third of the ado-

lescents spontaneously provided accounts of the difficulties

they experienced with taking oral medications, especially

with swallowing tablets. Three themes were dominant in

their narratives: barriers, strategies and learning. Barriers

experienced by the adolescents involved the medications’

properties, e.g. taste. Adolescents developed strategies to

overcome these barriers, e.g. crushing tablets. Via a pro-

cess of learning-by-doing and the acquisition of increased

experience and autonomy, many adolescents mastered the

skill of swallowing tablets. Conclusion Many adolescents

experienced barriers in their attempts to swallow tablets.

They developed various strategies to overcome these bar-

riers and gradually mastered taking medicines in a learn-

ing-by-doing process.

Keywords Adolescents � Children � Compliance �Denmark � Learning-by-doing � Medication use �Oral medications � Swallowing � Taste � User perspective

Introduction

Despite a growing awareness that children and adolescents’

health issues need to be taken seriously [1–3], medicine use

in this population is a neglected field in international re-

search. A few studies have demonstrated that children’s

medicine use patterns vary across age groups. Antibiotics

are primarily prescribed to young children [4, 5], while use

of medicine for aches is common among adolescents and is

seen to increase with their age [6, 7]. However, a couple of

studies, based on reports from parents or health care

personnel, have indicated that the mere act of taking

medicines may be troublesome to children, primarily due

to the medications’ taste [8, 9] and problems with swal-

lowing tablets [9]. Given that most medications are for-

mulated for oral administration [10], the ability to swallow

tablets is necessary when following most treatment regi-

mens. Studies about children’s difficulties with swallowing

tablets have focused specifically on the success of training

programs designed for children with chronic conditions

like Attention Deficit Hyperactivity Disorder and Autistic

Disorder [11, 12]. Thus, very little is known about the

medicine taking experiences of healthy children who do

not suffer from chronic conditions that require daily

medication.

The increasing use of medicines by age for common

health complaints among adolescents [6, 7] and the wide-

spread use among adults [13, 14] suggests that children, in

one way or another, learn to overcome their difficulties

taking medicines as they grow older. We have identified

D. L. Hansen (&) � D. Tulinius � E. H. Hansen

Faculty of Pharmaceutical Sciences, Department of

Pharmacology and Pharmacotherapy, FKL–Research Centre for

Quality in Medicine Use, University of Copenhagen,

Universitetsparken 2, Copenhagen DK-2100, Denmark

e-mail: dlh@farma.ku.dk

123

Pharm World Sci (2008) 30:65–69

DOI 10.1007/s11096-007-9142-y

one single study from Norway, which included general

practice patients spanning all age groups and showed that

patients’ difficulties swallowing tablets decreased mark-

edly with age [15].

Aim of the study

In this study, we aimed to explore adolescents’ struggles

with taking oral medications.

Methods

This study draws on pooled data from two data sets, con-

taining a total of 89 semi-structured qualitative interviews

with adolescents aged 11–20. Both sets of data were col-

lected as sub-studies in a collaborative project aimed at

obtaining an in-depth and multifaceted understanding of

children and adolescents’ experiences with medicines. All

participants were healthy adolescents recruited through

public schools in Copenhagen, Denmark. The first con-

tributing set of data included 69 11–15 year old boys and

girls, who were students from two public middle schools.

Included in the second set were 20 girls aged 16–20 who

were recruited via two public high schools.

As the objective was to obtain a deeper understanding of

the adolescents’ experiences with taking medicine, quali-

tative interviews were chosen for collection of data.

Interviews were carried out using a semi-structured inter-

view guide, which covered topics such as: experiences with

using medicine and perceptions of and attitudes towards

medicine and medicine taking. Before beginning the

interview, consent was obtained from the adolescents

themselves, their parents, or the school. Interviews with the

younger group of adolescents were conducted by DT.

These interviews took place in the school setting and las-

ted, on average, 50 min. DLH interviewed the older group

of girls in their own home or in an office at the university.

The average duration of the interviews was 70 min.

All interviews were tape recorded and transcribed ver-

batim. A preliminary analysis of the transcripts, done by

EHH, revealed experiences that were shared by both

groups of adolescents. One central unifying experience

appearing across age groups was the youths’ struggles with

taking oral medications. To further investigate this com-

mon element, each of the 89 interview transcripts was

searched systematically for the terms: swallow, chew,

crush and eat. Statements containing these terms were

gathered and transferred to analysis tables. Subsequently, a

thematic analysis via meaning condensation [16] was

carried out by all three researchers as a team. During

this interpretative phase, central themes were identified.

Statements from the entire interview set which pertained to

these themes were then grouped together. This step facil-

itated further conceptualization of the common essence of

the three main themes. In keeping with our focus on the

youths’ perspective, the themes that emerged were groun-

ded in the data, rather than inspired by an a priori theo-

retical framework [17].

Results

Analysis of the interviews revealed three dominating

themes about struggles with taking oral medications: bar-

riers, strategies and learning. Although not a focus in the

interview guides, over one-third (n = 32) of the adolescents

spontaneously provided lively descriptions of the difficul-

ties they had with taking oral medications, especially with

swallowing tablets. Various strategies were used by the

adolescents or their parents to overcome these problems

and some youths spoke proudly of the manner in which

they had now learned to swallow tablets. Table 1 outlines

the central elements within these three themes of barriers,

strategies and learning and the following section deals with

these themes in more detail.

Barriers

Many adolescents experienced barriers in relation to

swallowing tablets. A variety of factors were evident in the

barriers experienced by those who struggled with their

medicines. Most often, adolescents’ incapability to swal-

low tablets was due to their taste or size. Medicine’s taste

was generally viewed as a negative quality, as illustrated

by one girl’s animated account: ‘‘I hate those pills for

headache, because I think they taste a bit strange and then I

had to have it in my mouth, and it was so gross. Ugh ugh, I

hate it!’’ (age 11). Youths also discerned between large and

small tablets and spoke of the smaller tablets being easier

to swallow.

At the same time, adolescents’ feelings played a role in

their difficulties, as they either did not ‘‘like’’ or ‘‘feel like’’

Table 1 Characteristics of the three dominant themes

Barriers Strategies Learning

Taste Crushing or cutting Growing autonomy

Size Alternative

administration

Learning-by-doing

Feelings Taking with food Repetition and

perseverance

Bodily

discomfort

Taking with or without

water

Avoidance

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taking medicine. As one girl put it: ‘‘I’d rather avoid it

because I’m not too crazy about taking pills–I just don’t

like it’’ (age 11). Another declared: ‘‘they’re like really big

pills. I hate pills and the way they taste and stuff like that’’

(girl, age 18). These feelings, as well as the degree of

resistance to take medicine that resulted, varied among the

youths.

For several adolescents, the experience of bodily dis-

comfort in conjunction with swallowing tablets played a

role in their hesitance to take medicine. Some spoke of

sensations of feeling as though the tablet was caught in

their throat, while others described nausea or vomiting.

One 11 year old boy reported: ‘‘it makes me sick when I

swallow them or not sick like that, but I get this strange

feeling’’. Another boy stated: ‘‘I can’t stand taking pills. I

feel like throwing up, if I put a pill in my mouth’’ (age 15).

In spite of the experienced barriers, most adolescents

went along with taking medicine under certain circum-

stances, such as periods of more serious illness or strong

encouragement from their parents.

Strategies

Adolescents who experienced difficulties with swallowing

tablets also told of the manner in which they attempted to

overcome these barriers. These strategies usually involved

assistance from an adult, often the child’s mother. Of the

many strategies used to cope with these struggles, one of

them was to choose another form of administration, in

order to avoid taking a solid tablet. Adolescents mentioned

oral suspensions, effervescent tablets, and other alterna-

tives. Many spoke of having tablets crushed or divided, so

that they were easier to swallow. Other popular strategies

were taking tablets with food, such as yoghurt, or washing

the tablet down with large amounts of water.

A couple of youths spoke of less traditional methods,

where they, alone or with their parents, had developed

strategies for taking medicine. These strategies were often

employed in order to overcome the discomfort they expe-

rienced when swallowing solid tablets, as described in the

following two accounts:

‘‘And then my mom had to cut it in two, because it’s,

like, round...and then I had to take it. Then she just

threw it into my mouth and then I drank a lot of water

as quick as I could, it was so gross’’ (girl, age 11).

‘‘I take pills in a really strange way. I take some

food, chew it and then I put the pill—on my ton-

gue—while I still have that chewed up food in my

mouth and then I swallow. And then I drink a whole

lot of water after. Not too yummy, but it works for

me—then they make it down. Or else, if I take it at

night, after supper, then I have to take that pill and

then I eat—I don’t know—a cracker or some fruit

afterwards, just so that something can push it down.

Even though it’s probably already down in my

stomach—it just doesn’t feel that way. You can say to

your mom, ‘It’s right here!’’’ [points to her throat]

(girl, age 16).

Many adolescents felt such great aversion to taking tablets

that they tried to avoid taking them entirely. One 16 year

old girl described a particularly creative strategy: ‘‘When I

was younger, (smiling voice) my mom gave me calcium

pills and then I either stuffed them in my pocket or I cru-

shed them and put them up in the plant and then watered

them.’’ Others dealt with their difficulties by only going

along with taking medicine when they judged themselves

to be more seriously ill or felt unwell over longer periods of

time: ‘‘when it’s about being sick, being really sick, then

I’d rather take it than when I’m not really sick, seeing as I

don’t like it.’’ (boy, age 11). Another strategy was to cope

with symptoms by using alternative methods to taking

medicine: ‘‘I’ve been asked if I want a pill, but because I

don’t like swallowing it, I’d rather not take them, and be-

sides, I don’t think I need them, because...If I have a

headache, I drink some water, and then I lie down and relax

and then it goes away.’’ (girl, age 15).

Learning

As described above, many youths experienced the act of

swallowing a tablet as an insurmountable barrier and em-

ployed various strategies to help them overcome these

difficulties. Over time, most of these adolescents learned to

swallow tablets. One 11 year old boy recounted the manner

in which he went from having his tablets crushed to being

able to swallow first one half and later one or two whole

tablets:

‘‘So I had to crush my Panodil [acetaminophen]. It

tasted really bad! But I stopped doing that, or I

learned how to swallow them. You just have to take a

glass and then swallow, but I couldn’t do it at first, it

was as if it was stuck in my throat...but then I took

half at a time, half a Panodil [acetaminophen], be-

cause then it’s not so big. So I broke it in half then I

took it for 2 days, took half and then half. So finally, I

tried with a whole one, and I could do that too. And

now I can also take—or I think I could take 2 in a

row.’’

Those who had mastered the skill of swallowing tablets

used the term ‘‘learning’’ themselves, when describing this

new ability. An element of growing autonomy was also

present, as these adolescents had gone, for example, from

having their mother crush tablets for them to being able to

Pharm World Sci (2008) 30:65–69 67

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swallow a tablet without help from others. It was clear that

these youths had associated taking medicine with a multi-

tude of barriers and that they were relieved swallowing

tablets was no longer such a struggle. They viewed their

ability to swallow pills positively, as they spoke of being

‘‘lucky’’ to have finally learned it or how it was ‘‘cool’’ or

‘‘good’’ to be able to swallow. When the informants gave

these accounts of the learning process, their sense of pride

and accomplishment was evident, as expressed in the fol-

lowing quote from an 11 year old girl: ‘‘I’m really bad at

swallowing pills, but when I have finally swallowed it, I

think, ‘Mmm, that was well done!’’’

For most, repetition and experience was a key in their

learning process. Learning to swallow tablets was achieved

via learning-by-doing. These youths persevered until they

had finally grasped the technique: ‘‘So I try to put it in

there, and then, um, and then I take that one, and then I just

try to take a huge gulp of water and then I think, ‘Oh no,

it’s still there.’ And then I just keep on doing it.’’ (girl, age

11). One 12 year old boy described how he learned to

swallow tablets during a period of illness, during which he

was forced to take medicine repeatedly—often several

times a day:

‘‘But then once, I tried on my own. I put the pill in my

mouth and I tried to swallow it, but then it just lied

down there in the glass. And when I tried the next

time, I could do it, so that was really cool.’’

It was clear that several adolescents viewed learning to

swallow pills as a necessity, as they would not be able to

get well or treat their symptoms if they did not master this

skill. As an 11 year old boy described: ‘‘My mom just said

that I had to keep on trying, because it was very important

that I took those pills, because otherwise, it [sore from a

dog bite] might get infected.’’ The same consideration was

expressed by an 18 year old girl: ‘‘But I’ve gotten a bit used

to that, after I’ve started getting those menstrual

cramps—then you’ve got to swallow it.’’

Although adolescents generally got better at swallowing

tablets with age and experience, they were very different

with respect to their stage in this learning process. While

several of the younger children had already mastered the

skill, some of the older ones still struggled with taking

medicine.

Discussion

This study has been the first to explore children and ado-

lescents’ own perspective regarding the difficulties they

experience when taking medicines. Our main finding was

that barriers, strategies and learning were related to youths’

struggles with swallowing tablets. These findings have

several implications for pharmacy practice, which are

outlined in Box 1.

Box 1 This study’s implications for pharmacy practice

Difficulty or inability to swallow tablets could prevent adolescents

from accepting and adhering to necessary drug therapies.

Community and clinical pharmacists, as well as other health

practitioners, can enhance their quality of care for adolescents

through an awareness of the barriers they might struggle with and

by taking account of these barriers when dispensing or

recommending treatment.

Pharmacists are positioned well to help youths deal with difficulties,

and may harvest some inspiration from the strategies employed by

the adolescents in this study, i.e. choosing an alternative

administration route or crushing tablets, when appropriate.

Children and adolescents need to be taken seriously as active

participants in their own health care.

Our results concerning adolescents’ struggles with tak-

ing oral medications are in agreement with the studies we

have identified, two of which focus on children [8, 9], and a

third study [15] that includes results for younger age

groups in a general practice setting. The two previous

studies conducted on younger age groups [8, 9] were based

on reports by parents or health care personnel, rather than

from the children themselves. In addition, American [18]

and Finnish [19] studies have also revealed a process of

increasing autonomy in medicine taking. The learning

process described by adolescents in this study seems to be

one of learning-by-doing, rather than a cognitive devel-

opment process based on education and information. This

finding is in good accordance with the Finnish study of

children’s knowledge and attitudes towards medicines [19],

which found that children obtained their conceptions about

medicine through everyday experiences.

Semi-structured interviews proved to be a suitable

methodological tool for eliciting adolescents’ accounts, as

the youths provided rich descriptions of their medicine-

taking experiences. Discovery of the unforeseen themes

involving the youths’ struggles with swallowing tablets

was made possible due to our focus on the adolescents’

own perspective, as well as our grounded approach to

interview analysis. This study is thus able to contribute to a

deeper understanding of adolescents’ experiences with

these problems. The validity of our findings is supported by

the large size and diversity of the group of adolescents

interviewed. It was evident that struggles with swallowing

tablets was a prevailing experience for many of the ado-

lescents interviewed, as this theme emerged in spite of

differences in participant characteristics (e.g. age, school)

and interview form (e.g. interviewer and interview guide).

Researcher triangulation during the process of data analysis

acted to further strengthen the study’s validity.

68 Pharm World Sci (2008) 30:65–69

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However, this study’s limitations should also be noted.

Firstly, no insight has been provided into older teenage

boys’ experiences, due to the absence of boys in the older

age sample. Furthermore, since participants were recruited

in the school setting, less healthy children, who may have

been absent due to illness, are not represented in the group

of adolescents interviewed. These adolescents may have

been able to offer a different perspective, as they may have

more experiences with taking medicine. Finally, during

the process of identification of statements regarding

struggles with medicine taking, some statements may have

been overlooked, as adolescents may have used expres-

sions other than the four specific terms used in the analysis

search. Thus, this study’s results may underestimate the

difficulties experienced by the youths.

Conclusion

Adolescents have difficulties taking oral medications and

especially with swallowing tablets. Barriers such as med-

ication’s taste or bodily discomfort may make it difficult, if

not impossible, for many youths to swallow tablets. When

faced with barriers to taking medicines, adolescents can

develop strategies, with or without help from their parents,

to overcome them. Through repeated experience and

learning-by-doing, combined with increasing autonomy,

adolescents undergo a process of learning to swallow

tablets.

Acknowledgements This study was part of the authors’ employ-

ment at the Faculty of Pharmaceutical Sciences at the University of

Copenhagen.We would like to thank the adolescents who participated

in the interviews as well as the schools that provided assistance with

recruitment.

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