Determinants of poor adherence in hypertensive patients: development and validation of the "Maastricht Utrecht Adherence in Hypertension (MUAH)-questionnaire"

Design and validation of a new questionnaire with a gender perspective to measure medication adherence for secondary prevention of ischaemic heart disease: study protocol

INTRODUCTION AND OBJECTIVES

Only about 50% of chronic patients in high-income countries adhere to their treatment. There are methods to measure medication adherence but none of them can be considered optimal. This study will aim to design and validate a questionnaire to measure medication adherence in patients with ischaemic heart disease using a direct method as a gold-standard adherence measure and taking into account the gender perspective. Moreover, the profile of low adherence in these patients will be determined.

METHODS AND ANALYSIS

First study phase consists on the questionnaire design following the next steps: identification of the dimensions, definition of the target population, questionnaire items and order, response coding, questionnaire instructions, content validity by experts and understandability. In the second phase, a cross-sectional study will be performed to end the questionnaire development and validate it. Four hundred and forty patients (50% female) with acute coronary syndrome receiving treatment within the previous 12 months will be included. Patient will answer the initial questionnaire and adherence to aspirin and statin will be measured using a direct method (drug concentration analysis in blood) and other questionnaires. From the set of preselected questionnaire items, those most closely associated with the gold standard measure will be selected using multivariate statistics.

ETHICS AND DISSEMINATION

All participants gave their written informed consent before participating in the study. The study protocol follows the recommendations of the Declaration of Helsinki and was approved by the ethics committees of the three participating centres. The results of this study will be displayed at national and international conferences and in peer-reviewed scientific journals.

Remote follow-up by pharmacists for blood pressure control in patients with hypertension: a systematic review and a meta-analysis of randomized controlled trials

Hypertension is a major cause of cardiovascular diseases. Several recent studies reported that pharmacists' remote follow-up reduced hypertension patients' blood pressure (BP). This meta-analysis aims to verify whether remote follow-up by pharmacists improves BP levels and reveal the factors that make the intervention effective. The search, conducted using PubMed/Medline, Embase, and Cochrane Library from June to July 2023, targeted articles published between October 1982 and June 2023, using terms including "pharmacist", "hypertension", and "randomized controlled trial (RCT)". The inclusion criteria were: (a) RCTs involving hypertension patients with or without comorbidities, (b) pharmacists using remote communication tools to conduct follow-up encounter during the intervention period, (c) reporting systolic blood pressure (SBP) at baseline and during intervention. SBP was the primary outcome for the meta-analysis. Thirteen studies (3969 participants) were included in this meta-analysis. The mean difference of SBP between intervention group and control group was - 7.35 mmHg (P < 0.0001). Subgroup analyses showed the greater reduction of SBP in the "regularly scheduled follow-up cohort" (- 8.89 mmHg) compared with the "as needed follow-up cohort" (- 3.23 mmHg, P < 0.0001). The results revealed that remote follow-up by pharmacists reduced SBP levels in hypertension patients and scheduled remote follow-up may contribute to the effectiveness.

Development and validation of a Medication Adherence Universal Questionnaire: the MAUQ

BACKGROUND

Different questionnaires assess self-reported medication adherence and others quantify aspects of patients attitudes towards medication, but not together in a single instrument. Gathering these two aspects in a single instrument could reduce patients survey burden.

AIM

The aim of this study was to develop the Medication Adherence Universal Questionnaire (MAUQ) using the Maastricht Utrecht Adherence in Hypertension short version (MUAH-16) factorial structure as the hypothesized model.

METHOD

A multistep process started with the modification of the MUAH-16 to obtain the MAUQ. Patients using at least one antihypertensive medicine were recruited. The two questionnaires, the MUAH-16 and MAUQ, were applied. A confirmatory factor analysis (CFA) was performed using the initial MUAH-16 s-order 4-factor model. An additional bifactor model with four uncorrelated factors and an overall score was tested. The comparative fit index (CFI), root mean square error of approximation (RMSEA) with confidence intervals (CIs), and standardized root mean squared residual (SRMR) were used to assess both models.

RESULTS

A sample of 300 hypertensive patients completed the instruments. The CFA with the second-order 4-factor solution resulted in similar results for the MUAH-16 and MAUQ: CFIs of 0.934 and 0.930, RMSEAs of 0.043 [CI 0.030-0.056] and 0.045 [CI 0.031-0.057] and SRMRs of 0.060 and 0.061, respectively. The CFA with the bifactor model showed slightly better results for both the MUAH-16 and MAUQ: CFIs of 0.974 and 0.976, RMSEAs of 0.030 [CI 0.005-0.046] and 0.028 [CI 0.001-0.044], and SRMRs of 0.043 and 0.044, respectively.

CONCLUSION

CFA demonstrated that the MAUQ presented a better fit to both models than the MUAH-16, obtaining a robust universal free instrument to assess medicine-taking behaviour and four medicine beliefs components.

Test performance of self-report adherence tools in patients with hypertension: A systematic review and a meta-analysis

WHAT IS KNOWN AND OBJECTIVES

Adherence has proved to have a positive influence on achieving plausible treatment outcomes. Self-report questionnaires are widely used in evaluating adherence, creating thus a high-powered research field. This review aims to provide an update of scales used in hypertension, which are compared and analysed against reliability and validity.

METHODS

PubMed, Web of Science and Cochrane Library were searched in May 2022 to identify studies. We extracted the study characteristics and evaluated their quality. A random-effects model with subgroup analysis was used to calculate estimates and heterogeneity parameters as well as regressions, funnel and forest plots. A bivariate model was selected to conduct validity analyses and draw receiver operating characteristic (ROC) curves.

RESULTS AND DISCUSSION

Fifty-five articles were identified and classified into 22 different reliable and validated tools. Pooled analyses predicted an overall good Cronbach's alpha of 0.76 (95%CI:0.67-0.83), a good ICC of 0.8 (95%CI:0.72-0.86) and an excellent correlation coefficient of 0.91 (95%CI:0.86-0.95), which all showed high heterogeneity and slight detection of asymmetry. Regression analyses showed that only time and the number of items/scale type influenced significantly retest and alpha, respectively. Overall validity showed acceptable sensitivity of 0.65 (95%CI:0.53-0.75) and specificity of 0.57 (95%CI:0.47-0.67) with a good Area Under Curve (AUC) of 0.637. Upon comparison, four tools showed superiority over Morisky's scale.

WHAT IS NEW AND CONCLUSION

Adherence is a multi-dimensional phenomenon, which deems scales to be highly variable or complex; thus, complicating the selection process. Adherence to Refills and Medications Scale (ARMS) is the most promising free non-inferior alternative to Morisky, the most used scale.

Patient-reported outcome measures to detect intentional, mixed, or unintentional non-adherence to medication: a systematic review

OBJECTIVE

To categorise patient-reported outcome measures (PROMs) into their propensity to detect intentional and/or unintentional non-adherence to medication, and synthesise their psychometric properties.

DESIGN

Systematic review and regression analysis.

ELIGIBILITY

Medication adherence levels studied at primary, secondary and tertiary care settings. Self-reported measures with scoring methods were included. Studies without proxy measures were excluded.

DATA SOURCES

Using detailed searches with key concepts including questionnaires, reliability and validity, and restricted to English, MEDLINE, EMBASE, CINAHL, International Pharmaceutical Abstracts, and Cochrane Library were searched until 01 March 2022. Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA-2020) checklist was used.

DATA ANALYSIS

Risk of bias was assessed via COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN-2018) guidelines. Narrative synthesis aided by graphical figures and statistical analyses.

OUTCOME MEASURES

Process domains [behaviour (e.g., self-efficacy), barrier (e.g., impaired dexterity) or belief (e.g., perception)], and overall outcome domains of either intentional (I), unintentional (UI), or mixed non-adherence.

RESULTS

Paper summarises evidence from 59 studies of PROMs, validated among patients aged 18-88 years in America, the United Kingdom, Europe, Middle East, and Australasia. PROMs detected outcome domains: intentional non-adherence, n=44 (I=491 criterion items), mixed intentionality, n=13 (I=79/UI=50), and unintentional, n=2 (UI=5). Process domains detected include belief (383 criterion items), barrier (192) and behaviour (165). Criterion validity assessment used proxy measures (biomarkers, e-monitors), and scoring was ordinal, dichotomised, or used Visual Analogue Scale. Heterogeneity was revealed across psychometric properties (consistency, construct, reliability, discrimination ability). Intentionality correlated positively with negative beliefs (r(57)=0.88) and barriers (r(57)=0.59). For every belief or barrier criterion-item, PROMs' aptitude to detect intentional non-adherence increased by β=0.79 and β=0.34 units, respectively (R²=0.94). Primary care versus specialised care predicted intentional non-adherence (OR 1.9; CI 1.01 to 2.66).

CONCLUSIONS

Ten PROMs had adequate psychometric properties. Of the ten, eight PROMs were able to detect total, and two PROMs were able to detect partial intentionality to medication default. Fortification of patients' knowledge and illness perception, as opposed to daily reminders alone, is most imperative at primary care levels.

Measurement Properties of Patient-Reported Outcome Measures for Medication Adherence in Cardiovascular Disease: A COSMIN Systematic Review

BACKGROUND AND OBJECTIVE

Several medication adherence patient-reported outcome measures (MA-PROMs) are available for use in patients with cardiovascular disease (CVD); however, little evidence is available on the most suitable MA-PROM to measure medication adherence in patients with CVD. The aim of this systematic review is to synthesise the measurement properties of MA-PROMs for patients with CVD and identify the most suitable MA-PROM for use in clinical practice or future research in patients with CVD.

METHODS

An electronic search of nine databases (PubMed, MEDLINE, CINAHL, ProQuest Health and Medicine, Cochrane Library, PsychInfo, Scopus, Embase, and Web of Science) was conducted to identify studies that have reported on at least one of the measurement properties of MA-PROMs in patients with CVD. The methodological quality of the studies included in the systematic review was evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

RESULTS

A total of 40 MA-PROMs were identified in the 84 included studies. This review found there is a lack of moderate-to-high quality evidence of sufficient content validity for all MA-PROMs for patients with CVDs. Only eight MA-PROMs were classified in COSMIN recommendation category A. They exhibited sufficient content validity with very low-quality evidence, and moderate-to-high quality evidence for sufficient internal consistency. The 28 MA-PROMs that meet the requirements for COSMIN recommendation category 'B' require further validation studies. Four MA-PROMs including Hill-Bone Compliance Medication Scale (HBMS), the five-item Medication Adherence Report Scale (MARS-5), Maastricht Utrecht Adherence in Hypertension (MUAH), and MUAH-16 have insufficient results with high quality evidence for at least one measurement property and consequently are not recommended for use in patients with CVD. Two MA-PROMs (Adherence to Refills and Medications Scale [ARMS] and ARMS-7) are comprehensive and have moderate to high quality evidence for four sufficient measurement properties.

CONCLUSION

From the eight MA-PROMs in COSMIN recommendation category A, ARMS and ARMS-7 were selected as the most suitable MA-PROMs for use in patients with CVD. They are the most comprehensive with be best quality evidence to support their use in clinical practice and research.

A Scoping Review of Methods Used to Assess Medication Adherence in Patients with Chronic Conditions

BACKGROUND

Medication nonadherence of patients with chronic conditions is a complex phenomenon contributing to increased economic burden and decreased quality of life. Intervention development relies on accurately assessing adherence but no "gold standard" method currently exists.

PURPOSE

The present scoping review aimed to: (a) review and describe current methods of assessing medication adherence (MA) in patients with chronic conditions with the highest nonadherence rates (asthma, cancer, diabetes, epilepsy, HIV/AIDS, hypertension), (b) outline and compare the evidence on the quality indicators between assessment methods (e.g., sensitivity), and (c) provide evidence-based recommendations.

METHODS

PubMed, PsycINFO and Scopus databases were screened, resulting in 62,592 studies of which 71 met criteria and were included.

RESULTS

Twenty-seven self-report and 10 nonself-report measures were identified. The Medication Adherence Report Scale (MARS-5) was found to be the most accurate self-report, whereas electronic monitoring devices such as Medication Event Monitoring System (MEMS) corresponded to the most accurate nonself-report. Higher MA rates were reported when assessed using self-reports compared to nonself-reports, except from pill counts.

CONCLUSIONS

Professionals are advised to use a combination of self-report (like MARS-5) and nonself-report measures (like MEMS) as these were found to be the most accurate and reliable measures. This is the first review examining self and nonself-report methods for MA, across chronic conditions with the highest nonadherence rates and provides evidence-based recommendations. It highlights that MA assessment methods are understudied in certain conditions, like epilepsy. Before selecting a MA measure, professionals are advised to inspect its quality indicators. Feasibility of measures should be explored in future studies as there is presently a lack of evidence.

Development and validation of a questionnaire to determine medical orders non-adherence: a sequential exploratory mixed-method study

Background

Patients’ non-adherence with medical orders of physicians in outpatient clinics can lead to reduced clinical effectiveness, inadequate treatment, and increased medical care expenses. This study was conducted to develop and validate a questionnaire to determine the reasons for patients’ non-adherence with physicians’ medical orders.

Methods

A sequential exploratory mixed-method study was conducted in two stages. The first stage comprised a qualitative stage to generate the primary items of the questionnaire. This stage provided findings of two sub-stages comprising a literature review and the findings of a qualitative conventional content analysis of 19 semi-structured interviews held with patients, physicians, and managers of the outpatient clinics in Kerman, an area located in southeastern Iran. The second stage comprised a quantitative study aiming evaluation of the instrument psychometric properties, including the face, content, construct, and reliability assessment of the questionnaire. Construct validity assessment was evaluated using exploratory factor analysis (EFA). The reliability assessment was done using assessing internal consistency (Cronbach’s alpha). To assess the construct validity of the questionnaire, four hundred and forty patients referred to outpatient clinics in Kerman were selected using stratified convenience sampling to fill out the questionnaire. The sample size was calculated using the Cochran formula. Qualitative and quantitative data were analyzed by MAXQDA 10 and Stata version 14, respectively.

Results

The primary items contained 57 items, of which 42 met the minimum acceptable value of 0.78 for item-level content validity index (I-CVI = 1 for 24 items and I-CVI = 0.8 for 18 items). Item-level content validity ratio (I-CVR) was confirmed for 18 items with a minimum acceptable value of 0.99 for five experts. Finally, 18 items obtained the acceptable value for both I-CVI and I-CVR indicators and were confirmed. Using EFA, four factors (intrapersonal-psychological, intrapersonal-cognitive, provider-related, and socio-economic reasons) with 18 items and Cronbach’s alpha coefficient of 0.70, 0.66, 0.73, and 0.71, respectively, were identified and explained 51% of the variance. The reliability of the questionnaire (r = 0.70) was confirmed.

Conclusion

The questionnaire with four dimensions is a valid and reliable instrument that can help determine the perceived reasons for non-adherence with medical orders in the outpatient services system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06147-3.

Development of a PATIENT-Medication Adherence Instrument (P-MAI) and a HEALTHCARE PROFESSIONAL-Medication Adherence Instrument (H-MAI) using the nominal group technique

To date, several medication adherence instruments have been developed and validated worldwide. However, most instruments have only assessed medication adherence from the patient’s perspective. The aim was to develop and validate the PATIENT-Medication Adherence Instrument (P-MAI) and the HEALTHCARE PROFESSIONAL-Medication Adherence Instrument (H-MAI) to assess medication adherence from the patient’s and healthcare professional (HCP)’s perspectives. The P-MAI-12 and H-MAI-12 were developed using the nominal group technique. The face and content validity was determined by an expert panel and piloted. The initial version of these instruments consisted of 12 items were validated from October-December 2018 at a primary care clinic in Malaysia. Included were patients aged ≥21 years, diagnosed with diabetes mellitus, taking at least one oral hypoglycaemic agent and who could understand English. The HCPs recruited were family medicine specialists or trainees. To assess validity, exploratory factor analysis (EFA) and concurrent validity were performed; internal consistency and test-retest were performed to assess its reliability. A total of 120/158 patients (response rate = 75.9%) and 30/33 HCPs (response rate = 90.9%) agreed to participate. EFA found three problematic items in both instruments, which was then removed. The final version of the P-MAI-9 and the HMAI-9 had 9 items each with two domains (adherence = 2 items and knowledge/belief = 7 items). For concurrent validity, the total score of the P-MAI-9 and the H-MAI-9 were not significantly different (p = 0.091), indicating that medication adherence assessed from both the patient’s and HCP’s perspectives were similar. Both instruments achieved acceptable internal consistency (Cronbach’s α: P-MAI-9 = 0.722; H-MAI-9 = 0.895). For the P-MAI-9, 7/9 items showed no significant difference between test and retest whereas 8/9 items in the H-MAI-9 showed significant difference at test and retest (p>0.05). In conclusion, the P-MAI-9 and H-MAI-9 had low sensitivity and high specificity suggesting that both instruments can be used for identifying patients more likely to be non-adherent to their medications.

Greek Translation and Cultural Adaptation of the Short Version of the Maastricht Utrecht Adherence in Hypertension Questionnaire

BACKGROUND

The recently published short version of the Maastricht Utrecht Adherence in Hypertension (MUAH) questionnaire (MUAH-16) suggests that MUAH-16 better represents a patient's adherence to antihypertensive medication than the original MUAH questionnaire.

OBJECTIVE

The aim of our study was the cultural adaptation and validation of the short MUAH-16 questionnaire in the Greek population.

METHODS

10 patients were involved in the process of translation and cultural adaptation of MUAH-16, providing feedback on the final version, which was then administered to 100 patients. All patients received at least one antihypertensive drug during the last three months and were followed in the Hypertension-24h ABPM ESH Center of Excellence, Outpatient Clinic for the Treatment of Hypertension in the 3rd Internal Medicine Department of Papageorgiou General Hospital of Thessaloniki.

RESULTS

A factor analysis revealed a similar internal structure with four subscales that closely resembled the subscales in the original version of the questionnaire. Internal reliability indexes are equal or better than those of the original subscale structure.

CONCLUSIONS

The Greek translation of the MUAH-16 is a good match for the original version with small, cultural differences. More research is needed in order to validate the proposed revised internal structure with a larger sample.

Questionnaires on adherence to antihypertensive treatment: a systematic review of published questionnaires and their psychometric properties

Background Non-adherence to antihypertensive treatment is currently considered one of the most significant risk factors in failure to achieve controlled blood pressure values. It is therefore extremely important to measure patient adherence to antihypertensive treatment. One way to measure adherence is through questionnaires. Numerous questionnaires for measuring adherence to antihypertensive treatment have been validated, but it not easy to choose one of them as being more appropriate than all of the others. Aim of the review The aim of this study was to identify and assess questionnaires designed to measure non-adherence to antihypertensive treatment, and to discuss their psychometric properties. Method A systematic review of the literature contained in PubMed and Scopus databases was undertaken to identify validated questionnaires on adherence to antihypertensive treatment up to October 2017. PRISMA guidelines were followed to conduct and report this review. Selection of articles and data extraction were performed by two independent researchers. When there was lack of agreement, a third researcher mediated in the discussion between the first two authors so that consensus could be reached. Results 39 articles were obtained containing 17 different questionnaires for measuring adherence to antihypertensive treatment. These questionnaires were validated in 15 countries. The number of items in the questionnaires ranged from three in QAM-Q to 33 in TAQPH. Hill-Bone compliance to high blood pressure therapy scale, Morisky-Green-Levine test and an 8-item Self-Reported Medication Adherence Measurement were the most widely validated questionnaires. Validity was analyzed more than reliability. Many of the questionnaires do not provide information on content validity. Construct validity and concurrent validity are analyzed in almost all of the questionnaires, and give highly variable results. By contrast, known-groups validity was not analyzed to any great degree. As regards reliability, almost all of the questionnaires provided Cronbach's alpha information with reasonably acceptable results, but temporal stability was not analyzed to any great degree. Conclusion None of the questionnaires included in the review demonstrates fulfilling all of the validity tests (content validity, construct validity and criterion-related validity) and reliability tests (homogeneity and temporal stability) in an acceptable manner. Therefore, none of them can be considered a Gold Standard.

Adherence in Hypertension

The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.

Developing an adherence in hypertension questionnaire short version: MUAH-16

The Maastricht Utrecht Adherence in Hypertension (MUAH) questionnaire provides clinicians with information about the causes of a patient's poor adherence to antihypertensive drugs. In this study, the authors aimed to develop and validate a short version of the MUAH questionnaire. After an exploratory factor analysis, the number of MUAH items was reduced. The original MUAH questionnaire (model 1) was compared with the 16-item MUAH short version (model 2). Next, this short version of MUAH (MUAH-16) with all factors correlated (model 2a) was compared with the short version of MUAH with four subscales that contribute to a global factor of adherence (model 2b). Model 1 had a poor fit to the data (χ² 269 = 663.41, P < .001, comparative fit index = 0.695, root mean square error of approximation = 0.06), and model 2 had a very good fit to the data (χ² 100 = 171.07, P < .001, comparative fit index = 0.92, root mean square error of approximation = 0.04). When comparing model 2a with model 2b, the chi-square difference of the model (Δχ² 2 = 4.06; P = .067) revealed that the fits of both models were not significantly different. These findings suggest that MUAH-16 better represents a patient's adherence to antihypertensive medication than the original MUAH questionnaire.

Optimal cut-off value and clinical usefulness of the Adherence Starts with Knowledge-12 in patients with asthma taking inhaled corticosteroids

BACKGROUND

Non-adherence to inhalation regimens is common in asthmatic patients. The Adherence Starts with Knowledge-12 (ASK-12) survey was developed to detect and address patient-specific barriers to medication adherence. Our objective is to investigate the clinical usefulness of the ASK-12 for assessing and addressing adherence to inhalation therapy in asthma.

METHODS

The ASK-12 was administered to 138 asthmatic patients. Using pharmacy-refill data, we examined the cut-off value of the ASK-12 to identify patients who were non-adherent to inhalation regimens and identify factors associated with non-adherence. To verify the usefulness of the ASK-12, inhalation regimens were prospectively switched to less-expensive and simpler (once-daily) dosing regimens in eight non-adherent asthmatic patients who reported specific-barriers in "inconvenience of twice-daily inhaler use" and "cost".

RESULTS

Valid responses were received from 114 (82.6%) patients. A significant correlation was found between pharmacy-refill rates and the ASK-12 total score (r=-0.55, P<0.0001). The optimal cut-off value of the ASK-12 total score to discriminate non-adherent patients (defined by pharmacy-refill rate <80%) was 23, with 71.4% specificity and 93.3% sensitivity. Using this value, 52 (45.6%) patients were classified as non-adherent. Univariate followed by multivariate analysis identified younger age as a predictor of non-adherence to inhalation regimens (odds ratio, 2.67; 95% CI, -0.95 to -0.06; P=0.027). Switching inhaled medicines in eight patients resulted in significant improvements in both ASK-12 scores and asthma control.

CONCLUSIONS

The ASK-12 is a brief, practical, and clinically useful measure for assessing and addressing adherence to inhalation regimens in asthma.

Factors influencing the provision of adherence support by community pharmacists: A structural equation modeling approach

BACKGROUND

Non-adherence to medication represents an important barrier to achieving optimum patient outcomes. Community pharmacists are well placed to deliver interventions to support adherence.

AIMS

To investigate community pharmacists' activities in supporting patient adherence; and identify factors influencing pharmacists' provision of adherence support.

METHOD

A random sample of 2020 Australian community pharmacies was mailed a questionnaire investigating their provision of adherence support. The self-completed, structured questionnaire consisted of eight sections, five of which were relevant to this study: strategies used to identify non-adherent patients, strategies used to support patients' adherence to medications, pharmacists' attitudes toward provision of adherence support, perceived barriers to provision of adherence support, and demographics. Structural equation modeling (SEM) was used to determine potential influencing factors.

RESULTS

A response rate of 31% was achieved (n = 627). Pharmacists reported using strategies to identify non-adherent patients for less than half (45%) of the prescriptions dispensed. A mean of 8.4 ± 14.9 (mean ± SD) strategies was used by respondents in the 7 days prior to survey completion. Dose administration aids was the most commonly used strategy (provided by 96.5% of respondents). Time pressure for patients (68%) was perceived by pharmacists as the main barrier to adherence support. SEM identified "stakeholders/skills" and "number of full time equivalent staff" as influencing provision of adherence support strategies.

CONCLUSION

Provision of adherence support by pharmacists was episodic and infrequent, impeded by a number of barriers. By addressing barriers, it is possible to enable pharmacists to become more proactive and effective in supporting patient adherence.

Measuring self-care in patients with hypertension: a systematic review of literature

BACKGROUND

High blood pressure (HBP) self-care is critical for the control of HBP. Adequate measurement of HBP self-care is a necessary first step toward ameliorating the global pandemic of HBP.

OBJECTIVE

The aims of this study were to identify, describe, and critique existing HBP self-care instruments. The degree of adequacy of these instruments was evaluated against well-established behavioral guidelines for HBP care.

METHODS

This review was limited to articles published in English before October 2012. In addition, the following criteria were used: (1) the study described the validity and/or the reliability of a self-care/self-management instrument and (2) the study targeted patients with hypertension. Electronic database searches identified 1701 potentially relevant articles. Two authors reviewed the titles and the abstracts of all the retrieved articles independently. On the basis of the inclusion and the exclusion criteria, as well as cross-referencing, 29 articles were included in this review.

RESULTS

From the 29 articles, 19 unique HBP self-care instruments were identified (some were modified or translated versions of an original measure). Medication taking, a key domain of HBP self-care, was the main focus of 12 of the 19 instruments. Other key domains of HBP self-care were often missing or omitted. Seven instruments measured multiple dimensions of self-care; however, these either failed to capture all the main HBP self-care domains or had poor psychometric profiles. Nineteen of the 29 articles reported both validity and reliability, with varying degrees of rigor.

CONCLUSIONS

The current assessment tools do not capture all the critical elements of HBP self-care. The few instruments that attempted to measure the multiple behavioral dimensions of HBP self-care failed to report adequate levels of psychometric properties of those domains because of their incompleteness. Challenges remain in translating the HBP self-care guidelines into effective intervention and relevant assessment tools. Developing a valid and reliable instrument that captures the multidimensional nature of HBP self-care is urgently needed.

What are validated self-report adherence scales really measuring?: a systematic review

AIMS

Medication non-adherence is a significant health problem. There are numerous methods for measuring adherence, but no single method performs well on all criteria. The purpose of this systematic review is to (i) identify self-report medication adherence scales that have been correlated with comparison measures of medication-taking behaviour, (ii) assess how these scales measure adherence and (iii) explore how these adherence scales have been validated.

METHODS

Cinahl and PubMed databases were used to search articles written in English on the development or validation of medication adherence scales dating to August 2012. The search terms used were medication adherence, medication non-adherence, medication compliance and names of each scale. Data such as barriers identified and validation comparison measures were extracted and compared.

RESULTS

Sixty articles were included in the review, which consisted of 43 adherence scales. Adherence scales include items that either elicit information regarding the patient's medication-taking behaviour and/or attempts to identify barriers to good medication-taking behaviour or beliefs associated with adherence. The validation strategies employed depended on whether the focus of the scale was to measure medication-taking behaviour or identify barriers or beliefs.

CONCLUSIONS

Supporting patients to be adherent requires information on their medication-taking behaviour, barriers to adherence and beliefs about medicines. Adherence scales have the potential to explore these aspects of adherence, but currently there has been a greater focus on measuring medication-taking behaviour. Selecting the 'right' adherence scale(s) requires consideration of what needs to be measured and how (and in whom) the scale has been validated.

Understanding patients' adherence-related beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the Necessity-Concerns Framework

BACKGROUND

Patients' beliefs about treatment influence treatment engagement and adherence. The Necessity-Concerns Framework postulates that adherence is influenced by implicit judgements of personal need for the treatment (necessity beliefs) and concerns about the potential adverse consequences of taking it.

OBJECTIVE

To assess the utility of the NCF in explaining nonadherence to prescribed medicines.

DATA SOURCES

We searched EMBASE, Medline, PsycInfo, CDSR/DARE/CCT and CINAHL from January 1999 to April 2013 and handsearched reference sections from relevant articles.

STUDY ELIGIBILITY CRITERIA

Studies using the Beliefs about Medicines Questionnaire (BMQ) to examine perceptions of personal necessity for medication and concerns about potential adverse effects, in relation to a measure of adherence to medication.

PARTICIPANTS

Patients with long-term conditions.

STUDY APPRAISAL AND SYNTHESIS METHODS

Systematic review and meta-analysis of methodological quality was assessed by two independent reviewers. We pooled odds ratios for adherence using random effects models.

RESULTS

We identified 3777 studies, of which 94 (N = 25,072) fulfilled the inclusion criteria. Across studies, higher adherence was associated with stronger perceptions of necessity of treatment, OR = 1.742, 95% CI [1.569, 1.934], p<0.0001, and fewer Concerns about treatment, OR = 0.504, 95% CI: [0.450, 0.564], p<0.0001. These relationships remained significant when data were stratified by study size, the country in which the research was conducted and the type of adherence measure used.

LIMITATIONS

Few prospective longitudinal studies using objective adherence measures were identified.

CONCLUSIONS

The Necessity-Concerns Framework is a useful conceptual model for understanding patients' perspectives on prescribed medicines. Taking account of patients' necessity beliefs and concerns could enhance the quality of prescribing by helping clinicians to engage patients in treatment decisions and support optimal adherence to appropriate prescriptions.

The Reasoning and Regulating Medication Adherence Instrument for patients with coronary artery disease: development and psychometric evaluation

BACKGROUND

Many patients experience difficulty taking medications resulting in suboptimal adherence. Ambiguity surrounding adherence issues in chronic illness has been exacerbated by a lack of patient-centered, medication-specific, and theoretically integrative measurement instruments.

AIM

To develop a reliable and valid instrument to measure the factors that influence adherence in patients prescribed pharmacotherapy for coronary artery disease.

METHODS

Phase 1 involved the development of instrument structure and content. Constructs to be measured were defined through an analysis of adherence literature and qualitative interviews with patients. Phase 2 established the psychometric properties of the instrument. Exploratory factor analyses, reliability, and validity estimations were undertaken with a sample of patients (n = 404) from 3 tertiary cardiology referral centers.

RESULTS

Factor analyses resulted in a logically coherent, 16-item, three-factor solution that explained 50.5% variance. The factors were labelled: "Medication Planning Strategies," "Health Risk, and Health Protection." Internal consistency reliability met acceptable standards (alpha = .700 to alpha = .785). Fair to excellent intraclass correlations for temporal stability were demonstrated (.498-.882). Preliminary construct validity was supported by promising findings in relation to content validity results and factor structure stability.

CONCLUSIONS

A new adherence instrument for patients on pharmacotherapy for coronary artery disease has been developed and initial psychometric properties have been established. Additional instrument validation will be directed at further establishing construct and criterion-related validity. It is intended that this measure will be useful in identifying factors that impede or facilitate adherent behavior and contribute to advancing the science of instrument development within adherence research.

What are validated self-report adherence scales really measuring?: a systematic review

AIMS

Medication non-adherence is a significant health problem. There are numerous methods for measuring adherence, but no single method performs well on all criteria. The purpose of this systematic review is to (i) identify self-report medication adherence scales that have been correlated with comparison measures of medication-taking behaviour, (ii) assess how these scales measure adherence and (iii) explore how these adherence scales have been validated.

METHODS

Cinahl and PubMed databases were used to search articles written in English on the development or validation of medication adherence scales dating to August 2012. The search terms used were medication adherence, medication non-adherence, medication compliance and names of each scale. Data such as barriers identified and validation comparison measures were extracted and compared.

RESULTS

Sixty articles were included in the review, which consisted of 43 adherence scales. Adherence scales include items that either elicit information regarding the patient's medication-taking behaviour and/or attempts to identify barriers to good medication-taking behaviour or beliefs associated with adherence. The validation strategies employed depended on whether the focus of the scale was to measure medication-taking behaviour or identify barriers or beliefs.

CONCLUSIONS

Supporting patients to be adherent requires information on their medication-taking behaviour, barriers to adherence and beliefs about medicines. Adherence scales have the potential to explore these aspects of adherence, but currently there has been a greater focus on measuring medication-taking behaviour. Selecting the 'right' adherence scale(s) requires consideration of what needs to be measured and how (and in whom) the scale has been validated.

Interventions for improving adherence to ocular hypotensive therapy

BACKGROUND

Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open-angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information, teaching drop instillation technique and ongoing support according to the patient need may have a positive effect on improving adherence.

OBJECTIVES

To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 6), MEDLINE (June 1946 to June 2012), EMBASE (June 1980 to June 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 1937 to June 2012), PsycINFO (1806 to June 2012), PsycEXTRA (1908 to June 2012), Web of Science (1970 to June 2012), ZETOC (1993 to June 2012), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 June 2012. We did not search the National Research Register (NNR) as this resource has now been now archived. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We did not pool data due to clinical and methodological heterogeneity.

MAIN RESULTS

Sixteen trials (1565 participants) met the inclusion criteria. Seven studies investigated some form of patient education. In six of these studies this education was combined with other behavioural change interventions including tailoring daily routines to promote adherence to eye drops. Eight studies compared different drug regimens (one of these trials also compared open and masked monitoring) and one study investigated a reminder device. The studies were of variable quality and some were at considerable risk of bias; in general, the length of follow-up was short at less than six months with only two studies following up to 12 months. Different interventions and outcomes were reported and so it was not possible to produce an overall estimate of effect. There was some evidence from three studies that education combined with personalised interventions, that is, more complex interventions, improved adherence to ocular hypotensive therapy. There was less information on other outcomes such as persistence and intraocular pressure, and no information on visual field defects, quality of life and cost. There was weak evidence as to whether people on simpler drug regimens were more likely to adhere and persist with their ocular hypotensive therapy. A particular problem was the interpretation of cross-over studies, which in general were not reported correctly. One study investigated a reminder device and monitoring but the study was small and inconclusive.

AUTHORS' CONCLUSIONS

Although complex interventions consisting of patient education combined with personalised behavioural change interventions, including tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma medication, overall there is insufficient evidence to recommend a particular intervention. The interventions varied between studies and none of the included studies reported on the cost of the intervention. Simplified drug regimens also could be of benefit but again the current published studies do not provide conclusive evidence. Future studies should follow up for at least one year, and could benefit from standardised outcomes.

Self-reported adherence in patients with epilepsy who missed their medications and reasons for nonadherence in China

OBJECTIVES

The objectives of this study were: (1) to evaluate self-reported adherence in adult patients with epilepsy in China who had missed taking their antiepileptic drugs (AEDs) at least once and (2) to determine why patients were not adherent to their medication to employ interventions targeted at barriers to adherence.

METHODS

A questionnaire was used to collect the patients' demographic data, disease information, and reasons for why the patients did not take their AEDs. Adherence was also included as measured using a four-item Morisky questionnaire (Morisky-4 questionnaire).

RESULTS

Of the 131 patients, 4.6%, 70.2%, and 25.2% showed high, medium, and low adherence, respectively. The reasons for nonadherence included forgetfulness (54.2%), being seizure-free for a period (48.9%), and fear of adverse drug effects (27.5%).

CONCLUSIONS

Medium adherence was the predominant nonadherence pattern, and forgetfulness, being seizure-free for a period, and fear of adverse effects were the primary reasons for nonadherence to AEDs. To overcome barriers to nonadherence, it is essential to use tools that are sensitive to reasons for nonadherence.

Self-assessment tool for screening patients at risk for drug therapy problems

OBJECTIVE

To describe the development, use, and evaluation of a patient self-assessment tool for screening patients at risk for drug therapy problems (DTPs) and potentially interested in receiving a personal consultation with a pharmacist.

DESIGN

Quasi-experimental, nonrandomized, controlled study.

SETTING

Area Agency on Aging-affiliated senior centers in Florida from April 2005 to December 2005.

PARTICIPANTS

175 clients of an Area Agency on Aging.

INTERVENTION

While attending a free seminar on obtaining the best value from their medications, participants completed a 12-item self-assessment tool. The tool was designed to (1) identify participants who were at risk for a DTP and (2) motivate those at risk to participate in a personal pharmacotherapy consultation with a pharmacist on a fee-for-service basis.

MAIN OUTCOME MEASURE

Relationship between total score on self-assessment tool and patient acceptance of offer of personal pharmacotherapy consultation.

RESULTS

Of 175 participants who attended a free seminar, 69 (39.4%) accepted the offer of a personal pharmacotherapy consultation. The median score on the self-assessment tool in these participants was significantly higher compared with participants who declined a consultation (3 vs. 1, P = 0.0489). The number of DTPs eventually identified during the personal pharmacotherapy consultation was significantly and positively correlated with the total score on the self-assessment tool (ρ = 0.3259, P = 0.0110).

CONCLUSION

The self-assessment tool appeared to be of use in predicting individuals who were likely to accept the offer of a personal consultation. Higher scores on the self-assessment tool may also predict patients who are likely to have a higher number of DTPs.

Patient-specific factors relating to medication adherence in a post-percutaneous coronary intervention cohort

OBJECTIVE

To explore the association between medication adherence and qualitatively characterised patient-specific themes relating to medication adherence in patients following percutaneous coronary intervention (PCI).

METHODS

Data-collection questionnaires and qualitative topic guides were piloted in two patients. A validated questionnaire generated an adherence score for a convenience sample of 20 patients within 7 days of PCI. Semi-structured qualitative interviews were subsequently carried out with all patients to explore patient-specific themes relating to measured medication adherence.

KEY FINDINGS

Fourteen out of 20 patients (70%) had scores indicative of good adherence. Key factors associated with good adherence included having a good relationship with the doctor, having an understanding of the condition, knowledge of the indications and consequences of non-adherence, perceived health benefits and medications eliciting tangible symptom control. There were misconceptions of concern regarding adverse drug reactions and the importance of aspirin, both of which had a negative effect on adherence. The role of the community pharmacist was sometimes, although not always, misunderstood.

CONCLUSION

This study suggests there is an association between patients' beliefs, knowledge, understanding and misconceptions about medication and their adherence in a post-PCI cohort. To optimise medication adherence it is vital for prescribers to remain patient-focused and cognisant of patient-specific themes relating to medication adherence.

Evaluation of medication adherence methods in the treatment of malaria in Rwandan infants

Objectives

To compare three methods for evaluating treatment adherence in a 7-day controlled treatment period for malaria in children in Rwanda.

Methods

Fifty-six children (< 5 years) with malaria were recruited at the University Hospital of Butare, Rwanda. Patients were treated with quinine sulfate, taste-masked, pellets during seven days: three days in hospital (in-patient) followed by a four-day out-patient period. Three methods to evaluate medication adherence among patients were compared: manual pill count of returned tablets, patient self-report and electronic pill-box monitoring. These pill-boxes were equipped with a microchip registering date and time of every opening. Medication adherence was defined as the proportion of prescribed doses taken. The inter-dose intervals were analysed as well.

Results

Medication adherence data were available for 54 of the 56 patients. Manual pill count and patient self-report yielded a medication adherence of 100% for the in- and out-patient treatment periods. Based on electronic pill-box monitoring, medication adherence during the seven-day treatment period was 90.5 ± 8.3%. Based on electronic pill-box monitoring inpatient medication adherence (99.3 ± 2.7%) was markedly higher (p < 0.03) than out-patient adherence (82.7 ± 14.7%), showing a clear difference between health workers' and consumers' medication adherence.

Conclusion

Health workers' medication adherence was good. However, a significant lower medication adherence was observed for consumers' adherence in the outpatient setting. This was only detected by electronic pill-box monitoring. Therefore, this latter method is more accurate than the two other methods used in this study.

Improving medication uptake in aboriginal and Torres Strait islander peoples

BACKGROUND

Poor medication adherence is associated with adverse health outcomes. Improving access and adherence to pharmacological therapy is important in achieving optimal health outcomes for Indigenous populations. In spite of the impressive evidence base for cardiovascular pharmacotherapy, strategies for promoting adherence and evidence based practice are less well refined and the challenges for Indigenous populations are more pronounced.

AIM

To identify factors impacting on medication adherence in Aboriginal Australians and identify solutions to improve the quality use of medicines.

METHOD

The World Health Organization adherence model was used to classify barriers to adherence. Key elements of this model are (1) health care team/health system; (2) socio-economic factors; (3) therapy; (4) patient; and (5) condition related.

RESULTS

Entrenched socio-economic differentials aggravate challenges to medication adherence amongst Aboriginal Australians. Initiatives to promote the quality use of medicines, such as the Quality Use of Medicines Maximised for Aboriginal and Torres Strait Islander People (QUMAX) Program, are important strategies to promote adherence.

CONCLUSIONS

Medication adherence is a complex issue and addressing modifiable factors is imperative to improve health outcomes. Subsidised access to medications whether living in urban, regional, rural or remote areas is an important strategy in Closing the Gap.

Adherence rates and associations with nonadherence in patients with rheumatoid arthritis using disease modifying antirheumatic drugs

OBJECTIVE

Nonadherence in patients with rheumatoid arthritis (RA) using disease modifying antirheumatic drugs (DMARD) may result in unnecessarily high levels of disease activity and function loss. The aim of this descriptive study was to assess adherence rates with self-report measures in a large random population, and to identify potential risk factors for nonadherence.

METHODS

A randomly selected sample of 228 patients with RA using DMARD was invited for a standardised interview. For each medicine, the patients were asked about adherence, consumption and perceived (side) effects. After the interview, the patients received self-report questionnaires to assess adherence [Compliance Questionnaire on Rheumatology (CQR) and the Medication Adherence Scale (MARS)], coping, beliefs about medicines, satisfaction about medicine information, and physical functioning. Subsequently, associations between adherence and demographics, clinical characteristics, and patient attitudes were examined.

RESULTS

Depending on the instrument used, 68% (CQR) and 60% (MARS) of the patients were adherent to DMARD. Nonadherence was not associated with demographic and clinical characteristics, satisfaction about information, medication concerns, and coping styles. The disease duration, the number of perceived side-effects, and beliefs about the necessity of the medicine were weakly associated with adherence.

CONCLUSION

In this large study with a random RA population, 32%-40% of the patients did not adhere to their DMARD prescription. As none of the possible risk factors was strongly related to adherence, no general risk factor seems to be powerful enough as a possible screening tool or target for adherence-improving interventions. This implies that nonadherence barriers should be assessed on an individual basis.

Interventions for improving adherence to ocular hypotensive therapy

BACKGROUND

Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information and ongoing support according to patient need, may have a positive effect on improving adherence.

OBJECTIVES

To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, ZETOC and OpenSIGLE. In addition, we searched research registers of ongoing studies. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO). There were no language or date restrictions in the search for trials. The electronic databases were last searched on 15 January 2009.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We calculated the mean difference for continuous data and relative risks for dichotomous data. Where appropriate, we pooled data using a fixed-effect model.

MAIN RESULTS

Eight trials met the inclusion criteria. There was considerable heterogeneity of interventions and reported outcome measures and therefore, meta-analysis was limited to two studies. Overall, studies were not of high quality due to small sample sizes, missing data and short term follow-up. Three of five drug comparison studies provided evidence that reducing the frequency of drops can improve adherence. However, the study that compared the least frequent regime with one of the most complicated, showed no difference in reported adherence. A small study of thirteen patients found a reminder device beneficial to adherence levels yet only one of two studies involving education and individualised care planning was found to be successful.

AUTHORS' CONCLUSIONS

Interventions involving simplified dosing regimes, reminder devices, education and individualised care planning, did show improvements in adherence rates. However, due to inadequate methodological quality and heterogeneity of study design we are unable to advocate any particular interventions at this time.

Physicians' ability to predict patients' adherence to antihypertensive medication in primary care

Addressing adherence to medication is essential and notoriously difficult. The purpose of this study was to determine physicians' ability to predict patients' adherence to antihypertensive therapy. Primary care physicians were asked to predict the adherence to medication of their hypertensive patients (n=42) by using a visual analogue scale (VAS) at the beginning of the study period. The patients were asked to report their adherence to medication using a VAS. The adherence was then monitored by using a Medical Event Monitoring System (MEMS) for 42+/-14 d. The means+/-SD (range) of MEMS measures for timing adherence, correct dosing, and adherence to medication were 82+/-27% (0 to 100%), 87+/-24% (4 to 100%), and 94+/-18% (4 to 108%), respectively. The physicians' prediction of their patients' adherence was 92+/-15%. The Spearman rank correlations between the physician's prediction and the MEMS measures of timing adherence, correct dosing, and adherence to medication was 0.42 (p=0.006), 0.47 (p=0.002), and -0.02 (p=0.888), respectively. The patients reported their own adherence to medication at 98+/-2% (range 83 to 100%). The Spearman correlations between the reported and actual behaviours were 0.27 (p=0.08) for timing adherence, 0.25 (p=0.12) for correct dosing, and 0.11 (p=0.51) for adherence to medication. The physicians' ability to predict patients' adherence to antihypertensive medication is limited and not accurate for identifying non-adherent patients in clinical practice. Even patients themselves are unable to give accurate reports of their own adherence to medication.

The Adherence Estimator: a brief, proximal screener for patient propensity to adhere to prescription medications for chronic disease

OBJECTIVE

To conceptualize, develop, and provide preliminary psychometric evidence for the Adherence Estimator--a brief, three-item proximal screener for the likelihood of non-adherence to prescription medications (medication non-fulfillment and non-persistence) for chronic disease.

RESEARCH DESIGN AND METHODS

Qualitative focus groups with 140 healthcare consumers and two internet-based surveys of adults with chronic disease, comprising a total of 1772 respondents, who were self-reported medication adherers, non-persisters, and non-fulfillers. Psychometric tests were performed on over 150 items assessing 14 patient beliefs and skills hypothesized to be related to medication non-adherence along a proximal-distal continuum. Psychometric tests included, but were not limited to, known-groups discriminant validity at the scale and item level. The psychometric analyses sought to identify: (1) the specific multi-item scales that best differentiated self-reported adherers from self-reported non-adherers (non-fulfillers and non-persisters) and, (2) the single best item within each prioritized multi-item scale that best differentiated self-reported adherers from self-reported non-adherers (non-fulfillers and non-persisters).

RESULTS

The two rounds of psychometric testing identified and cross-validated three proximal drivers of self-reported adherence: perceived concerns about medications, perceived need for medications, and perceived affordability of medications. One item from each domain was selected to include in the Adherence Estimator using a synthesis of psychometric results gleaned from classical and modern psychometric test theory. By simple summation of the weights assigned to the category responses of the three items, a total score is obtained that is immediately interpretable and completely transparent. Patients can be placed into one of three segments based on the total score--low, medium, and high risk for non-adherence. Sensitivity was 88%--of the non-adherers, 88% would be accurately classified as medium or high risk by the Adherence Estimator. The three risk groups differed on theoretically-relevant variables external to the Adherence Estimator in ways consistent with the hypothesized proximal-distal continuum of adherence drivers.

CONCLUSIONS

The three-item Adherence Estimator measures three proximal beliefs related to intentional non-adherence (medication non-fulfillment and non-persistence). Preliminary evidence of the validity of the Adherence Evidence supports its intended use to segment patients on their propensity to adhere to a newly-prescribed prescription medication. The Adherence Estimator is readily scored and is easily interpretable. Due to its brevity and transparency, it should prove to be practical for use in everyday clinical practice and in disease management for adherence quality improvement. Study limitations related to sample representation and self reports of chronic disease and adherence behaviors were discussed.

Development of the ASK-20 adherence barrier survey

OBJECTIVE

Poor medication adherence is widespread among patients with chronic conditions requiring long-term drug therapy. Medication adherence is determined by multiple patient-, context-, and therapy-dependent factors. This paper describes the development and initial validation of the ASK-20 survey, created to identify actionable risk factors for medication nonadherence and to improve communication about adherence.

METHODS

A pool of 30 items was generated through comprehensive literature review. Items were refined and the item pool was expanded through an expert panel review and patient focus groups to yield 47 candidate items, each with five response options ranging from either Strongly Agree to Strongly Disagree or from In the Last Week to Never. The pool of 47 candidate items was administered to a web-based sample of 605 patients taking medications and reporting a diagnosis of asthma, diabetes, or depression for psychometric testing and item reduction.

RESULTS

Eleven multi-item factor groupings with two additional unique items were identified on the basis of principal components analysis and interpretability. Twenty (20) items representing ten factor groupings were selected for the final instrument. Each of the final items was dichotomized as positive - indicating a barrier, or negative. Two summary scores - the sum of all positive barriers or Total Barrier Count (TBC) and the sum of raw item scores, the ASK-20 score - were calculated. Concurrent validity of the dichotomously scored individual items, the TBC and ASK-20 scores in relation to self-reported adherence was generally good. Cronbach's alpha coefficient was 0.77 for the TBC and 0.85 for the ASK-20 score.

CONCLUSIONS

ASK-20 consists of 20 clinically actionable items representing multiple factors that affect medication adherence. The ASK-20 survey demonstrated satisfactory validity and internal consistency and may be used to identify actionable barriers to adherence across a spectrum of chronic diseases. Future research using more objective measures of adherence is warranted to confirm the exploratory validity and reliability of ASK-20 reported in this study.

Social context, the struggle with uncertainty, and subjective risk as meaning-rich constructs for explaining HBP noncompliance

OBJECTIVE

To identify the reasons for which people fail to take blood-pressure-lowering medication regularly, a qualitative study was conducted.

METHODS

Interviews lasting approximately 90 min were conducted with 27 patients (15 women, 12 men) aged 40-70. The verbatim of the 27 interviews was first read and divided into segments with explanatory value. This was followed by the production of a final text in vignette form for all interviews. An integrative, analytical phase consisted of identifying trends, significant central themes, regularities, and divergences in the vignettes.

RESULTS

Analysis revealed the explanatory power that 3 broad groups of subjective meanings could hold for given medication noncompliance scenarios. These scenarios are expressing the role of: (1) stress and living conditions in the occasional skipping or deferral of medication-taking; (2) doubt as the motivating factor for transitory, irregular medication use; (3) subjective risk as the motivating factor for persistent irregular use.

CONCLUSION

Life and social contexts, doubt and risk subsume extremely meaning-rich constructs that can help identify dilemmas facing people about medication-taking.

PRACTICE IMPLICATIONS

By discussing these dimensions with their patients, health professionals will be better able to understand patient medication behaviors that sometimes run counter to their recommendations.