Design and rationale of a mixed methods randomized control trial: ADdressing Health literacy, bEliefs, adheRence and self-Efficacy (ADHERE) program to improve diabetes outcomes

Investigation of Barriers and Facilitators to Medication Adherence in Patients With Type 2 Diabetes Across Different Health Literacy Levels: An Explanatory Sequential Mixed Methods Study

Type 2 diabetes (T2D) incurs tremendous healthcare costs associated with various complications due to poor blood sugar control. Medication adherence, which is correlated with patients’ health literacy, should be consistently practiced to achieve optimal control of blood sugar. A comprehensive understanding of specific communication and psychosocial factors related to medication-taking behaviors across different levels of health literacy among people with T2D will guide the development of effective interventions and strategies to enhance medication adherence. To understand barriers and facilitators to medication adherence in people with T2D across different health literacy levels, the Health Literacy Pathway Model was used to identify the psychosocial and communication factors that may influence medication adherence. This mixed methods study used an explanatory sequential design, including a quantitative survey followed by qualitative semi-structured interviews. Two hundred and five participants completed the survey questionnaire, and 23 participants completed semi-structured interviews. Confirmed by quantitative and qualitative data, having stronger self-efficacy and fewer concerns about medications, as well as experiencing fewer perceived barriers to medication-taking, are necessary for better medication adherence among those with low adherence. Our findings will be useful to tailor interventions for diabetes care through addressing concerns among low-adherent patients with low health literacy and emphasizing self-efficacy and perceived barriers to medication adherence among all low-adherent patients with T2D.

Best practices for conducting and writing mixed methods research in social pharmacy

Mixed method approaches are increasingly being used in social pharmacy research due to its potential to uncover insights that are not possible with separate quantitative and qualitative studies. Despite their increasing use, there are some limitations in these publications. Typically, specific mixed method designs are not chosen, quantitative and qualitative data are not systematically integrated, and the credibility or validity of the approach is not addressed. In this paper, we discuss mixed method designs and their applications in social pharmacy. Different integration techniques and legitimation types are detailed. We describe new methodological developments and provide examples from recent mixed method studies in social pharmacy. Finally, we also provide recommendations for planning, conducting, reporting, and evaluating mixed method studies. We suggest that researchers interested in conducting mixed method studies follow recommended guidelines and obtain training in mixed methods to ensure that rigorous mixed method studies are conducted in social and administrative pharmacy.

Diabetes status modifies the efficacy of home-based kidney care for Zuni Indians in a randomized controlled trial

BACKGROUND

Home-Based Kidney Care (HBKC) is a pragmatic treatment approach that addresses patient preferences and cultural barriers to healthcare. We previously reported the results of a clinical trial of HBKC vs. usual care in a cohort of Zuni Indians in New Mexico. This study investigated the potential for differential efficacy of HBKC vs. usual care according to type 2 diabetes (T2DM) status.

METHODS

We analyzed the data from all individuals who participated in a randomized clinical trial that compared HBKC to usual care among patients with CKD, and assessed whether the effect of the HBKC intervention affected the subset of patients with T2DM differently than those individuals without T2DM. We used linear regression models to estimate the effect of HBKC on improvement in Patient Activation Measure (PAM) total scores within the groups of participants defined by T2DM status, and to compare the effects between these two groups. We used generalized estimating equations (GEE) to account for household clustering.

RESULTS

The original study enrolled 63 participants into the HBKC group, and 62 into the usual care. Ninety-eight of these individuals completed the 12-month intervention, 50 in the HBKC group and 48 in the usual care group. The present study compared the intervention effect in the 56 participants with T2DM (24 participants in the HBKC group and 32 in usual care) to the intervention effect in the 42 participants without T2DM (26 participants in the HBKC group and 16 in usual care). Those with T2DM who received the HBKC intervention experienced an average increase in PAM total scores of 16.0 points (95% Confidence Interval: 8.8-23.1) more than those with T2DM who were in the usual care group. For those without T2DM, the intervention had essentially no effect, with those who received the HBKC intervention having an average PAM total scores that was 1.4 points (95% C.I.: -12.4 to 9.6) lower than those who received usual care. There was a significantly different HBKC treatment effect by T2DM status (p = 0.02).

CONCLUSION

This secondary analysis suggests that the effectiveness of this HBKC intervention on increasing patient activation is most notable among those CKD patients who also have T2DM.

Conceptualization, Development and Psychometric Evaluations of a New Medication-Related Health Literacy Instrument: The Chinese Medication Literacy Measurement

There is a need for valid and reliable instruments to focus on medication aspects of health literacy and help healthcare professionals address patients’ barriers to medication use. This cross-sectional study describes the conceptualization, development, and psychometric properties of the first Chinese Medication Literacy Measurement (ChMLM) to assess the level of health literacy on medication use. The 17-item ChMLM (ChMLM-17) and its short form, 13-item ChMLM (ChMLM-13), consist of four sections (vocabulary, over-the-counter labels, prescription labels, and advertisements) to cover six domains of medication-related health literacy. Multistage stratified quota sampling was attempted to recruit a representative sample in Taiwan. Receiver operating characteristic curves were used to identify the cut-off point for differentiating high and low medication literacy. Psychometric analyses were performed (n = 1410) to assess the reliability and validity separately on all samples and sociodemographic subgroups. The 17- and 13-item versions both had high construct validity among all patients and patients with low medication literacy. The developed ChMLM-17 and ChMLM-13 is expected to help healthcare providers and researchers to accurately measure medication-related health literacy and improve medication use in the real-world practice.

Patient factors associated with diabetes medication adherence at different health literacy levels: a cross-sectional study at a family medicine clinic

BACKGROUND

Type 2 diabetes (T2D) incurs tremendous health costs associated with various complications due to poor diabetes control. Medication adherence, which is correlated with patients' health literacy, should be consistently practiced achieving optimal diabetes control. A deeper understanding of the specific communication and psychosocial factors related to medication-taking behaviors across different levels of health literacy among people with T2D will guide the development of effective interventions and strategies to enhance medication adherence.

OBJECTIVES

This cross-sectional study aimed to identify salient patient factors associated with diabetes medication adherence across different levels of health literacy.

METHODS

A questionnaire was administered via a face-to-face approach with 205 participants at a family medicine clinic. Study participants were all above 20 years of age with T2D, were prescribed at least one oral diabetes medication, and understood English. The questionnaire assessed participants' health literacy, self-efficacy for medication use, beliefs in medicines, patient-provider communication, perceived barriers to medication adherence, and self-reported medication adherence. Separate analysis of covariance was used to compare the mean scores of patient factors related to medication adherence across people with different health literacy levels.

RESULTS

The mean age of participants was 61 years old, and the majority of the participants were female (57%), White (75%), and college educated (62%). Thirty-three percent of the participants had adequate health literacy, but only 43% of them reported high adherence to their diabetes medications. Analysis of covariance showed that having stronger self-efficacy (P < 0.001), lower concern beliefs about medication (P = 0.047), and fewer perceived barriers to medication-taking (P < 0.001), are necessary for better medication adherence.

CONCLUSION

Findings suggest that practitioners should address concern beliefs among low-adherent patients with low health literacy, help improve self-efficacy, and address perceived barriers to medication adherence among all low-adherent patients to optimally support patients' diabetes care.

Diabetic health literacy and its association with glycemic control among adult patients with type 2 diabetes mellitus attending the outpatient clinic of a university hospital in Ethiopia

BACKGROUND

Despite how much effect of low health literacy is on diabetic treatment cannot be accurate, it has an impact on controlling blood glucose level. Less is known about diabetic health literacy in Ethiopian diabetic patients which can affect patient medication adherence, self-care, and glycemic control.

OBJECTIVE

This study was aimed to assess the diabetic health literacy level and its association with glycemic control among adult patients with type 2 diabetes mellitus attending the outpatient clinic of University of Gondar Comprehensive Specialized Hospital (UOGCSH): Northwest Ethiopia.

METHODS

A cross-sectional study was employed at the outpatient clinic of the University of Gondar Comprehensive Specialized Hospital from May, 1 -May 30, 2019. The comprehensive 15-items diabetic health literacy questions with a 5-point Likert scale used to measure diabetic health literacy. The mean score calculated and switched to the percentage (5 points as 100%) to determine the level of diabetic health literacy. Morisky Green Levine Scale 4 item adherence assessment tool was used to assess the diabetic patient's level of adherence. Binary and multivariable logistic regression analysis was used to assess the association between sociodemographic, clinical variables, diabetic-related literacy, and glycemic control. Independent samples t-test and One-way ANOVA test was employed to compare the mean literacy score difference in different groups.

RESULT

400 respondents were included in the study. Of all the respondents, 17.3%, 26.3%, and 56.5% had low, medium and high diabetic-related health literacy, respectively. The proportions of patients with low, medium and high adherence to medication were 9.8%, 56.3%, and 34% respectively. Patients with high diabetes literacy are 1.85 times more likely to achieve target glycemic control than lower diabetic literacy patients with 95% CI Adjusted Odds Ratio (AOR). 1.85(1.09-3.40). While patients with good adherence 1.61 times more likely to achieve target glycemic control than patients with low adherence; 95% CI AOR 1.61(1.04-4.79). Diabetic patients with morbidity have 67% less likelihood to achieve the target glycemic control; 95% CI AOR 0.33(0.15-0.73).

CONCLUSION

Adequate diabetic health literacy and better glycemic control are highly correlated. Adjusting all variables; younger age, high diabetic health literacy and good adherence are associated with achieving the target glycemic control.