Beliefs of chronically ill Japanese patients that lead to intentional non-adherence to medication

Prevalence and Patient-Level Correlates of Intentional Non-Adherence to Immunosuppressive Medication After Heart-Transplantation-Findings From the International BRIGHT Study

After heart transplantation (HTx), non-adherence to immunosuppressants (IS) is associated with poor outcomes; however, intentional non-adherence (INA) is poorly understood regarding its international variability in prevalence, contributing factors and impact on outcomes. We investigated (1) the prevalence and international variability of INA, (2) patient-level correlates of INA, and (3) relation of INA with clinical outcomes. Secondary analysis of data from the BRIGHT study-an international multi-center, cross-sectional survey examining multi-level factors of adherence in 1,397 adult HTx recipients. INA during the implementation phase, i.e., drug holiday and dose alteration, was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale© (BAASIS©). Descriptive and inferential analysis was performed with data retrieved through patient interview, patient self-report and in clinical records. INA prevalence was 3.3% (n = 46/1,397)-drug holidays: 1.7% (n = 24); dose alteration: 1.4% (n = 20); both: 0.1% (n = 2). University-level education (OR = 2.46, CI = 1.04-5.83), insurance not covering IS costs (OR = 2.21, CI = 1.01-4.87) and barriers (OR = 4.90, CI = 2.73-8.80) were significantly associated with INA; however, clinical outcomes were not. Compared to other single-center studies, this sample's INA prevalence was low. More than accessibility or financial concerns, our analyses identified patient-level barriers as INA drivers. Addressing patients' IS-related barriers, should decrease INA.

The rate of medication nonadherence and influencing factors: A systematic Review

Lack of adherence to recommended therapy will reduce its effectiveness and can subsequently lead to disease progression, disabilities or even death. A vast number of research studies have emphasized the magnitude of medication nonadherence and its effect on treatment outcomes, patient’s health, healthcare providers and the associated costs; medication nonadherence remains a major concern that is believed to be widely practiced amongst medication taking patients. The current systemic review aims to cohere the available evidence regarding medication nonadherence rate, practices, and potential affecting factors and predictors. A search through different databases was conducted, including PubMed, Medline, and CINHAL for recently published research articles, within five years. The terms used for the search include medication nonadherence, medication nonadherence, factors affecting medication nonadherence and predictors of medication nonadherence. The search was limited to human subjects, English language journal articles and exclusion of review articles, case studies, and data from clinical trials as patient adherence is closely observed.<br /> The search resulted in 667 articles and only 65 articles were included and further screened. However, according to our exclusion criteria, 15 articles only were included in this review. The three most reported practices of medication nonadherence are prescription abandonment, nonconforming, and non-persistence. There are five reported factors that may lead to nonadherence practices such as socioeconomic-related factors, healthcare system-related factors, patient-related factors, disease-related factors, and therapy-related factors. In conclusion, medication nonadherence practice is a multi-dimensional phenomenon that requires a multi-targeted solution.

Feasibility and Quality Validation of a Mobile Application for Enhancing Adherence to Opioids in Sickle Cell Disease

Prescription opioid nonadherence, specifically opioid misuse, has contributed to the opioid epidemic and opioid-related mortality in the US. Popular methods to measure and control opioid adherence have limitations, but mobile health, specifically smartphone applications, offers a potentially useful technology for this purpose. We developed, tested, and validated the OpPill application using the Mobile Applications Rating Scale (MARS), a validated tool for assessing the quality of mobile health apps. The MARS contains four scales (range of each scale = 0–4) that rate Engagement, Functionality, Aesthetics, and Information Quality. It also assesses subjective quality, relevance, and overall application impact. Our application was built to be a mobile monitoring and reporting system intended to enhance opioid adherence by collecting data and providing systematic feedback on pain and opioid use. Patients (n = 28) all had one of various SCD genotypes, were ages 19 to 59 years (mean 36.56), 53.6% were female, and 39.3% had completed some college. Patients rated the OpPill application highly on all four scales: Engagement, 3.93 ± 0.73; Functionality, 4.54 ± 0.66; Aesthetics, 3.92 ± 0.81; Information, 3.91 ± 0.87. The majority of patients found the application to be relevant for their care. A total of 96% reported the information within the app was complete, while 4% estimated the information to be minimal or overwhelming. Patients (91.7%) overwhelmingly reported that the quality of information as it pertained to SCD patients was relevant; only 8.3% found the application to be poorly relevant to SCD. Similarly, patients (91.7%) overwhelmingly rated both the application’s performance and ease of use positively. The large majority of participants (85.7%) found the application to be interesting to use, while 74% found it entertaining. All users found the application’s navigation to be logical and accurate with consistent and intuitive gestural design. We conclude that the OpPill application, specifically targeted to monitor opioid use and pain and opioid behavior in patients with Chronic Non-Cancer Pain, was feasible and rated by SCD patients as easy-to-use using a validated rating tool.

Factors affecting self-management of hypertensive patients attending family medicine clinics in Riyadh, Saudi Arabia

Background/Aim:

Hypertension (HBP) is a chronic disease that has become a public health problem, which has been attributed to numerous risk factors. However, despite numerous HBP management and behavioral treatment guidelines, HBP is poorly controlled among patients due to insufficient care. We conducted this study to identify the prevalence of self-management behaviors and to explore factors affecting self-management behaviors for controlling HBP among hypertensive patients.

Methods:

We conducted a survey using the Hypertension Self-Care Profile (HBP-SCP) and the Hill-Bone Adherence Scale among diagnosed HBP patients attending the Family Medicine clinics of King Saud Medical City in Riyadh, Saudi Arabia in January 2019. All patients of Saudi nationality aged 18 years and above were included in the study.

Results:

A total of 187 patients responded to the survey, 95 (50.8%) males and 92 (49.2%) females. Only 93 patients (49.7%) monitor their BP at home, and 68 (36.4%) always measure their BP. Ninety-one patients (48.7%) said that measuring their BP is not important. The most common reason for not taking the anti-HBP medications is they forget to take the medications in 87 (46.5%) of patients. Seventy-two patients (38.5%) did not restrict salt intake, and 51 patients (27.3%) had no time for exercise. More than half of the patients (51.3%) were not motivated to regularly exercise and 56.7% were motivated to limit salt-intake. Confidence to exercise, check BP at home, and eat low-salt foods were also low at 52.4–53.5%. Significant factors including gender, age, BMI, duration of HBP, and presence of cardiac disease were found to be related toward behavior, motivation, and confidence to self-care.

Conclusion:

Compliance, behavior, motivation, and self-care among hypertensive patients visiting the primary care clinics in our representative population are low. Various factors were found to be related to poor behavior, poor motivation, and less confidence to do home BP monitoring, to exercise more, restrict salt intake, and value the control of HBP. There is a need for health practitioners to assess self-care activities and blood pressure control, and educate patients the importance of HBP monitoring and teaching practical techniques to boost their confidence and motivation to achieve a better behavior, self-care, and compliance to management.

Effective factors in non-compliance with therapeutic orders of specialists in outpatient clinics in Iran: a qualitative study

Background

Non-compliance with prescribed treatment is an important cause of preventable mortality and economic burden. Recognition of the factors for non-compliance with the therapeutic orders of specialists from the perspective of patients and health care providers sheds more light on the issue for policymakers and stakeholders. The current study aimed at determining the factors for non-compliance with therapeutic orders in outpatient clinics in Kerman, Iran.

Methods

The current qualitative study was conducted using the phenomenological method and semi-structured interviews with 10 patients, five specialists, and four health care managers and treatment officials in outpatient clinics in Kerman. The interviewees were selected by purposive sampling. The codes extracted from the interviews were transcribed using conventional content analysis to identify the viewpoints. The MAXQDA 10 software was used to analyze the data.

Results

The reasons for non-compliance with specialists’ orders were categorized into five themes including patient-related (patient-centered), disease-related, therapy-related, the healthcare provider related (healthcare system), and socioeconomic factors. Themes were composed of fifteen categories and forty-one sub-categories. The dominant sub-categories extracted from interviews were health literacy and knowledge of the patient, communication and patients’ trust in physicians and direct costs of treatment.

Conclusion

This study identified a wide range of different individual, disease, treatment, health care provider, and socio-economic factors and the interactions between them which may result into non-compliance with therapeutic orders prescribed by specialists. Therefore, specific attention should be paid to integrate the service provision system into the collaborative approach of the patient and his/her family in order to promote the level of compliance with therapy and care in planning and policy-making to improve the health service provision system.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4229-4) contains supplementary material, which is available to authorized users.

Medication concordance in modern medicine - A critical appraisal from an Indian perspective

Modern medicine encompasses a holistic approach toward patient care that seeks to integrate the social, psychological, and pathological aspects of a disease. In line with this, the traditional model of improving treatment outcomes through improved compliance or adherence has given way to the concept of “concordance” that respects the integrity of the patient, autonomy, and self-determination. A self-conscious patient actively and equally participating in her or his comprehensive healthcare can bring a paradigm shift in the perceptions and functioning of the healthcare sector. Medication concordance can be expected to play a key role in improving patient well-being, clinical outcomes, and healthcare delivery. However, it is fraught with numerous questions to be addressed ranging from lack of clarity or standard protocol, medicolegal intricacies, cultural–linguistic barriers, illiteracy, shortage of time, infrastructure, and manpower. There are major challenges in the effective implementation of this initiative which has definite potential to prove beneficial in Indian healthcare settings. The success of this novel approach can only be accomplished by coordinated, inclusive, and persistent efforts from all participants of healthcare with fostering of a milieu of trust, belief, and communication. A systematic literature search was conducted using key words from relevant articles and MeSh terms on Google Scholar and PubMed. Data were abstracted according to their relevance to subheadings of the review and synthesis of concepts was done through multiple reviews by atleast two reviewers for any subsection.

Quality Measurement and Improvement Study of Surgical Coronary Revascularization: Medication Adherence (MISSION-2)

Background

Secondary preventive therapies play a key role in the prevention of adverse outcomes after coronary artery bypass grafting (CABG). However, medication adherence after CABG is often poor, and conventional interventions for improving adherence have limited success. With increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve adherence. Carefully designed trials are needed to provide reliable evidence for the use of these applications in patients after CABG.

Methods

The Measurement and Improvement Studies of Surgical Coronary Revascularization: Medication Adherence (MISSION-2) study is a multicenter randomized controlled trial, aiming to randomize 1000 CABG patients to the intervention or control groups in a 1:1 ratio. We developed the multifaceted, patient-centered, smartphone-based Heart Health Application to encourage medication adherence in the intervention group through a health self-management program initiated during hospital admission for CABG. The application integrated daily scheduled reminders to take the discharge medications, cardiac educational materials, a dynamic dashboard to review cardiovascular risk factors and secondary prevention targets, and weekly questionnaires with interactive feedback. The primary outcome was secondary preventive medication adherence measured by the Chinese version of the 8-item Morisky Medication Adherence Scale at 6 months after randomization. Secondary outcomes included all-cause death, cardiovascular rehospitalization, and a composite of death, myocardial infarction, stroke, and repeat revascularization.

Discussion

Findings will not only provide evidence regarding the feasibility and effectiveness of the described intervention for improving adherence to CABG secondary preventive therapies but also explore a model for outpatient health self-management that could be translated to various chronic diseases and widely disseminated across resource-limited settings.

Trial Registration

https://clinicaltrials.gov (NCT02432469).

Predictors of Noncompliance to Antihypertensive Therapy among Hypertensive Patients Ghana: Application of Health Belief Model

This study determined noncompliance to antihypertensive therapy (AHT) and its associated factors in a Ghanaian population by using the health belief model (HBM). This descriptive cross-sectional study conducted at Kintampo Municipality in Ghana recruited a total of 678 hypertensive patients. The questionnaire constituted information regarding sociodemographics, a five-Likert type HBM questionnaire, and lifestyle-related factors. The rate of noncompliance to AHT in this study was 58.6%. The mean age (SD) of the participants was 43.5 (±5.2) years and median duration of hypertension was 2 years. Overall, the five HBM constructs explained 31.7% of the variance in noncompliance to AHT with a prediction accuracy of 77.5%, after adjusting for age, gender, and duration of condition. Higher levels of perceived benefits of using medicine [aOR=0.55(0.36-0.82),p=0.0001] and cue to actions [aOR=0.59(0.38-0.90),p=0.0008] were significantly associated with reduced noncompliance while perceived susceptibility [aOR=3.05(2.20-6.25), p<0.0001], perceived barrier [aOR=2.14(1.56-2.92), p<0.0001], and perceived severity [aOR=4.20(2.93-6.00),p<0.0001] were significantly associated with increased noncompliance to AHT. Participant who had completed tertiary education [aOR=0.27(0.17-0.43), p<0.0001] and had regular source of income [aOR=0.52(0.38-0.71), p<0.0001] were less likely to be noncompliant. However, being a government employee [aOR=4.16(1.93-8.96), p=0.0002)] was significantly associated increased noncompliance to AHT. Noncompliance to AHT was considerably high and HBM is generally reliable in assessing treatment noncompliance in the Ghanaian hypertensive patients. The significant predictors of noncompliance to AHT were higher level of perceived barriers, susceptibility, and severity. Intervention programmes could be guided by the association of risk factors, HBM constructs with noncompliance to AHT in clinical practice.

Beliefs about hydroxyurea in youth with sickle cell disease

BACKGROUND

Hydroxyurea reduces complications and improves health-related quality of life (HRQOL) in sickle cell disease (SCD) patients, however adherence remains suboptimal. Understanding patients' views of hydroxyurea is critical to optimize adherence, particularly in adolescents and young adults (AYA). Study objectives were to assess beliefs about hydroxyurea using the Beliefs about Medicines Questionnaire (BMQ), and to examine the relationship of patients' beliefs to their hydroxyurea adherence and HRQOL.

METHODS

Thirty-four AYA with SCD participated in a cross-sectional study January-December 2015. Study assessments included BMQ to examine beliefs about hydroxyurea; Visual Analogue Scale (VAS) to assess hydroxyurea adherence; and Patient Reported Outcomes Measurement Information System (PROMIS®) to evaluate HRQOL.

RESULTS

Participants (41% female, 91% Black) had median age of 13.5 (IQR 12-18) years. Participants' concerns about overuse of medications correlated with concerns about hydroxyurea (r_s = 0.36, p = 0.04) and overall harm of medications (r_s = 0.5, p = 0.003). Participants' age positively correlated with the necessity of hydroxyurea (r_s = 0.45, p = 0.007). Participants' concerns about hydroxyurea and overuse of medications positively correlated with anxiety (r_s = 0.41, p = 0.02; r_s = 0.44, p = 0.01) and depression (r_s = 0.37, p = 0.04; r_s = 0.54, p = 0.001), but inversely correlated with peer relationships (r_s = -0.45, p = 0.03; r_s = -0.44, p = 0.03), respectively, suggesting better HRQOL with concerns. Fifty percent of participants reported low hydroxyurea adherence (VAS < 80%), which was more seen in patients with higher concerns about hydroxyurea (p = 0.02).

CONCLUSIONS

Beliefs about hydroxyurea correlated with HRQOL scores and adherence levels. Addressing patients' concern about hydroxyurea and medications overall as well as routine assessment of adherence and beliefs could help to overcome adherence barriers.

Intentional Nonadherence as a Means to Exert Control

Medication adherence is a major issue for patients with a chronic illness, who sometimes rationally choose temporary nonadherence. This study aims at better understanding intentional nonadherence and especially why it seems to fluctuate over time. It is based on 48 semi-structured interviews conducted in a hospital in the Netherlands with patients who had been prescribed a medication for a chronic disease for at least 1 year, and who had either type 2 diabetes, hypertension, Parkinson's disease, inflammatory bowel disease, or chronic myeloid leukemia. The analysis uses a simplified version of the failure modes and effects analysis (FMEA) method. Intentional nonadherence appeared to be the result of the respondents' desire (a) to exert control over the treatment and its effects on their body, and (b) to control the hold of the treatment on their daily life. This result provides a rationale for the fluctuation of intentional nonadherence behavior.

Assessing the Medication Adherence App Marketplace From the Health Professional and Consumer Vantage Points

Background

Nonadherence produces considerable health consequences and economic burden to patients and payers. One approach to improve medication nonadherence that has gained interest in recent years is the use of smartphone adherence apps. The development of smartphone adherence apps has increased rapidly since 2012; however, literature evaluating the clinical app and effectiveness of smartphone adherence apps to improve medication adherence is generally lacking.

Objective

The aims of this study were to (1) provide an updated evaluation and comparison of medication adherence apps in the marketplace by assessing the features, functionality, and health literacy (HL) of the highest-ranking adherence apps and (2) indirectly measure the validity of our rating methodology by determining the relationship between our app evaluations and Web-based consumer ratings.

Methods

Two independent reviewers assessed the features and functionality using a 4-domain rating tool of all adherence apps identified based on developer claims. The same reviewers downloaded and tested the 100 highest-ranking apps including an additional domain for assessment of HL. Pearson product correlations were estimated between the consumer ratings and our domain and total scores.

Results

A total of 824 adherence apps were identified; of these, 645 unique apps were evaluated after applying exclusion criteria. The median initial score based on descriptions was 14 (max of 68; range 0-60). As a result, 100 of the highest-scoring unique apps underwent user testing. The median overall user-tested score was 31.5 (max of 73; range 0-60). The majority of the user tested the adherence apps that underwent user testing reported a consumer rating score in their respective online marketplace. The mean consumer rating was 3.93 (SD 0.84). The total user-tested score was positively correlated with consumer ratings (r=.1969, P=.04).

Conclusions

More adherence apps are available in the Web-based marketplace, and the quality of these apps varies considerably. Consumer ratings are positively but weakly correlated with user-testing scores suggesting that our rating tool has some validity but that consumers and clinicians may assess adherence app quality differently.

Factors influencing oral adherence: qualitative metasummary and triangulation with quantitative evidence

BACKGROUND

Concern about adherence to oral agents among patients with cancer has grown as more oral agents are being used for cancer treatment. Knowledge of common factors that facilitate or inhibit adherence to oral medication regimens can be beneficial to clinicians in identifying patients at risk for nonadherence, in planning care to address barriers to adherence, and in educating patients about ways to improve adherence.

OBJECTIVES

The focus of this review is to synthesize the evidence about factors that influence adherence and identify implications for practice.

METHODS

Literature was searched via PubMed and CINAHL®. Evidence regarding factors influencing adherence was synthesized using a metasummary of qualitative research and triangulated with findings from quantitative research.

FINDINGS

Forty-four factors influencing adherence were identified from 159 research studies of patients with and without cancer. Factors associated with adherence in oncology and non-oncology cases included provider relations, side effects, forgetfulness, beliefs about medication necessity, establishing routines for taking medication, social support, ability to fit medications in lifestyle, cost, and medication knowledge. Among patients with cancer, depression and negative expectations of results also were shown to have a negative relationship to adherence.

Psychosocial factors related to non-persistence with adjuvant endocrine therapy among women with breast cancer: the Breast Cancer Quality of Care Study (BQUAL)

Non-adherence to adjuvant endocrine therapy (ET) for breast cancer (BC) is common. Our goal was to determine the associations between psychosocial factors and ET non-persistence. We recruited women with BC receiving care in an integrated healthcare system between 2006 and 2010. Using a subset of patients treated with ET, we investigated factors related to ET non-persistence (discontinuation) based on pharmacy records (≥90 days gap). Serial interviews were conducted at baseline and every 6 months. The Functional Assessment of Cancer Therapy (FACT), Medical Outcomes Survey, Treatment Satisfaction Questionnaire (TSQM), Impact of Events Scale (IES), Interpersonal Processes of Care measure, and Decision-making beliefs and concerns were measured. Multivariate models assessed factors associated with non-persistence. Of the 523 women in our final cohort who initiated ET and had a subsequent evaluation, 94 (18 %) were non-persistent over a 2-year follow-up. The cohort was primarily white (74.4 %), stage 1 (60.6 %), and on an aromatase inhibitor (68.1 %). Women in the highest income category had a lower odds of being non-persistent (OR 0.43, 95 % CI 0.23-0.81). Quality of life and attitudes toward ET at baseline were associated with non-persistence. At follow-up, the FACT, TSQM, and IES were associated with non-persistence (p < 0.001). Most women continued ET. Women who reported a better attitude toward ET, better quality of life, and more treatment satisfaction, were less likely to be non-persistent and those who reported intrusive/avoidant thoughts were more likely to be non-persistent. Interventions to enhance the psychosocial well-being of patients should be evaluated to increase adherence.

Assessment of medication adherence app features, functionality, and health literacy level and the creation of a searchable Web-based adherence app resource for health care professionals and patients

OBJECTIVES

To assess the features and level of health literacy (HL) of available medication adherence apps and to create a searchable website to assist health care providers (HCP) and patients identify quality adherence apps.

PRACTICE DESCRIPTION

Medication nonadherence continues to be a significant problem and leads to poor health outcomes and avoidable health care expense. The average adherence rate for chronic medications, regardless of disease state, is approximately 50% leaving significant room for improvement.

PRACTICE INNOVATION

Smartphone adherence apps are a novel resource to address medication nonadherence. With widespread smartphone use and the growing number of adherence apps, both HCP and patients should be able to identify quality adherence apps to maximize potential benefits.

INTERVENTIONS

Assess the features, functionality and level of HL of available adherence apps and create a searchable website to help both HCP and patients identify quality adherence apps.

EVALUATION

Online marketplaces (iTunes, Google Play, Blackberry) were searched in June of 2014 to identify available adherence apps. Online descriptions were recorded and scored based on 28 author-identified features across 4 domains. The 100 highest-scoring apps were user-tested with a standardized regimen to evaluate their functionality and level of HL.

RESULTS

461 adherence apps were identified. 367 unique apps were evaluated after removing "Lite/Trial" versions. The median initial score based on descriptions was 15 (max of 68; range: 3 to 47). Only 77 apps of the top 100 highest-scoring apps completed user-testing and HL evaluations. The median overall user-testing score was 30 (max of 73; range: 16 to 55).

CONCLUSION

App design, functionality, and level of HL varies widely among adherence apps. While no app is perfect, several apps scored highly across all domains. The website www.medappfinder.com is a searchable tool that helps HCP and patients identify quality apps in a crowded marketplace.

Exploring the factors that influence medication rating Web sites value to older adults: A cross-sectional study

In this cross-sectional study, we evaluated factors that affected the perceived value of medication rating Web sites to 284 people aged ≥ 60 years who were taking prescription medications. The Patient Reviews of Medication Experience (PROMEX) questionnaire score, which assessed participant opinions about the value of online reviews of medications, was positively associated with preference to share health care decision making with the health care provider and negatively associated with the Physical Component Summary (PCS-12) and Mental Component Summary scores of the Short Form 12 health survey. The Primary Care Assessment Survey Communication score, which measured participant satisfaction with the communication from the health care provider, was positively associated with PCS-12 and health literacy. In summary, older adults who had poor physical and mental health-related quality of life were more likely to believe that medication rating Web sites were useful and helpful in facilitating communication with health care providers.

Are Australian clinicians monitoring medication adherence in hematological cancer survivors? Two cross-sectional studies

Background

Hematological cancer survivors are growing in number and increasingly rely on oral therapy. Given known poor outcomes associated with non-adherence and previous evidence that many patients do not fully adhere to their treatment regimen, this study aimed to determine the degree to which clinicians monitor adherence to oral medication in hematological cancer survivors.

Methods

Data was combined from two cross-sectional surveys of a heterogeneous sample of 431 hematological cancer survivors recruited from three outpatient hematology clinics in three different states (n = 215) and one state cancer registry (n = 216) in Australia. Participants completed a self-administered survey that included demographic characteristics and a 7-item measure of medication adherence developed by the researchers specifically for the purpose of the studies.

Results

Of the 431 participants, 37 % (n = 160) reported currently taking daily cancer-related medication. Of these, 14 % (n = 23) were found to be non-adherent with ‘missing a dose’ being the most commonly reported non-adherent behaviour. Only 41 % of survivors indicated that their hematologist or cancer clinician had ‘always’ asked about their cancer-related medication during their last six visits.

Conclusions

Non-adherence to oral therapy remains a problem in hematological cancer survivors, yet clinicians in Australia do not appear to be regularly monitoring adherence in their patients. Given an increasing dependence on oral therapy in clinical hematology and medical oncology and the importance of medication adherence to optimising health outcomes, greater effort should be invested in developing effective interventions to improve support and adherence monitoring by cancer clinicians and GPs.

Future perspectives of Smartphone applications for rheumatic diseases self-management

Rheumatic diseases (RD) self-management interventions are designed to improve health-related quality of life, health care utilization, and perceived self-efficacy. Despite these demonstrated good results, there are several issues that hinder or render less appealing these interventions. One economically and socially viable solution is exploiting the potential of Smartphone technology. This potential comes from Smartphones pervasive presence in actual society, combined with the advantages of being personal, intuitive, and computationally powerful, with capability to support applications and assist its user throughout different activities of daily living and environments persistently. With their global acceptance increasing quickly, there is a great opportunity for mobile health in using Smartphone applications for RD self-management. Besides the potential of such applications, research on the development and evaluation of such applications is in the early stages. Therefore, it is important to foresee its future applicability in order to meet the needs of the twenty-first century.

Beliefs About Medicines and Self-reported Adherence Among Patients with Chronic Illness: A Study in Palestine

BACKGROUND

Identifying factors associated with adherence is of great value in clinical practice. The objective of this study was to investigate medication adherence, beliefs about medicines held by people with chronic illness and whether beliefs influence medication adherence.

METHODS

The study was carried out at primary health care clinic of the Palestinian Medical Military Services in Nablus, Palestine. The beliefs about medicines questionnaire was used to assess beliefs and Morisky medication adherence scale was used to assess adherence.

RESULTS

A total of 187 patients were interviewed. Most participants (79.6%) agreed or strongly agreed that their medications were necessary for their current health. However, 58.2% of the participants were concerned about having to take their medicines on a regular basis and 57.8% were concerned about becoming dependent on their medicines. None of the demographic and clinical variables was significantly associated with medication adherence. However, multivariate analysis showed that patients who had higher beliefs about medication necessity had higher odds (1.107 [1.023-1.197]) of being adherent. On the other hand, patients who had higher concern beliefs had lower odds (0.908 [0.845-0.975]) of being adherent.

CONCLUSIONS

Beliefs about medicines are a major contributing factor to medication adherence.

Smartphone medication adherence apps: potential benefits to patients and providers

OBJECTIVES

To provide an overview of medication adherence, discuss the potential for smartphone medication adherence applications (adherence apps) to improve medication nonadherence, evaluate features of adherence apps across operating systems (OSs), and identify future opportunities and barriers facing adherence apps.

PRACTICE DESCRIPTION

Medication nonadherence is a common, complex, and costly problem that contributes to poor treatment outcomes and consumes health care resources. Nonadherence is difficult to measure precisely, and interventions to mitigate it have been largely unsuccessful.

PRACTICE INNOVATION

Using smartphone adherence apps represents a novel approach to improving adherence. This readily available technology offers many features that can be designed to help patients and health care providers improve medication-taking behavior.

MAIN OUTCOME MEASURES

Currently available apps were identified from the three main smartphone OSs (Apple, Android, and Blackberry). In addition, desirable features for adherence apps were identified and ranked by perceived importance to user desirability using a three-point rating system: 1, modest; 2, moderate; or 3, high. The 10 highest-rated apps were installed and subjected to user testing to assess app attributes using a standard medication regimen. RESULTS 160 adherence apps were identified and ranked. These apps were most prevalent for the Android OS. Adherence apps with advanced functionality were more prevalent on the Apple iPhone OS. Among all apps, MyMedSchedule, MyMeds, and RxmindMe rated the highest because of their basic medication reminder features coupled with their enhanced levels of functionality.

CONCLUSION

Despite being untested, medication apps represent a possible strategy that pharmacists can recommend to nonadherent patients and incorporate into their practice.

Influence of patients' disease knowledge and beliefs about medicines on medication adherence: findings from a cross-sectional survey among patients with type 2 diabetes mellitus in Palestine

BACKGROUND

Diabetes mellitus (DM) is a common serious health problem. Medication adherence is a key determinant of therapeutic success in patients with diabetes mellitus. The purpose of this study was to assess medication adherence and its potential association with beliefs and diabetes - related knowledge in patients with type II DM.

METHODS

This study was carried out at Al-Makhfia governmental diabetes primary healthcare clinic in Nablus, Palestine. Main outcome of interest in the study was medication adherence. The Beliefs about Medicines Questionnaire (BMQ) was used to assess beliefs. Morisky Medication Adherence Scale (MMSA-8©) was used to assess medication adherence. The Michigan diabetes knowledge test (MDKT) was used to assess diabetes - related knowledge. Univariate and multivariate analysis were carried out using Statistical Package for Social Sciences (SPSS 20).

RESULTS

Four hundred and five patients were interviewed. The mean ± SD age of the participants was 58.3 ± 10.4 (range = 28 - 90) years. More than half (53.3%) of the participants were females. Approximately 42.7% of the study sample were considered non-adherent (MMAS-8© score of < 6). Multivariate analysis showed that the following variables were significantly associated with non-adherence: disease-related knowledge, beliefs about necessity of anti-diabetic medications, concerns about adverse consequences of anti-diabetic medications and beliefs that medicines in general are essentially harmful. Diabetic patients with high knowledge score and those with strong beliefs in the necessity of their anti-diabetic medications were less likely to be non-adherent ([O.R = 0.87, 95% CI of 0.78 - 0.97] and [O.R = 0.93, 95% of 0.88 - 0.99] respectively). However, diabetic patients with high concerns about adverse consequences of anti-diabetic medications and those with high belief that all medicines are harmful were more likely to be non-adherent ([O.R = 1.09; 95% C.I of 1.04 - 1.16] and [O.R = 1.09, 95% C.I of 1.02 - 1.16] respectively).

CONCLUSIONS

Beliefs and knowledge are important factors in understanding variations in medication adherence among diabetic patients. The BMQ can be used as a tool to identify people at higher risk of non-adherence. Improving knowledge of patients about their illness might positively influence their medication adherence.

Non-initiation of adjuvant hormonal therapy in women with hormone receptor-positive breast cancer: The Breast Cancer Quality of Care Study (BQUAL)

Adjuvant hormonal therapy for non-metastatic hormone receptor (HR)-positive breast cancer decreases risk of breast cancer recurrence and increases survival. However, some women do not initiate this life-saving treatment. We used a prospective cohort design to investigate factors related to non-initiation of hormonal therapy among women with newly diagnosed, non-metastatic HR-positive breast cancer recruited from three U.S. sites. Serial interviews were conducted at baseline and during treatment to examine sociodemographic factors, tumor characteristics, and treatment decision-making factors. Multivariate modeling assessed associations between variables of interest and hormonal therapy initiation. Of 1,050 breast cancer patients recruited, 725 (69%) had HR-positive breast cancer, of whom 87 (12.0%) based on self-report and 122 (16.8%) based on medical record/pharmacy fill rates did not initiate hormonal therapy. In a multivariable analysis, non-initiation of hormonal therapy, defined by medical record/pharmacy, was associated with having greater negative beliefs about efficacy of treatment (OR 1.42, 95% CI 1.18-1.70). Non-initiation was less likely in those who found the quality of patient/physician communication to be higher (OR 0.96, 95% CI 0.93-0.99), the hormonal therapy treatment decision an easy one to make (OR 0.45, 95% CI 0.23-0.90) or neither easy nor difficult (OR 0.34, 95% CI 0.20-0.58); and had more positive beliefs about hormonal therapy efficacy (OR 0.40, 95% CI 0.34-0.62). Factors influencing non-initiation of adjuvant hormonal therapy are complex and influenced by patient beliefs regarding treatment efficacy and side effects. Educational interventions to women about the benefits of hormonal therapy may decrease negative beliefs and increase hormone therapy initiation.

Factors affecting therapeutic compliance: A review from the patient's perspective

Objective

To explore and evaluate the most common factors causing therapeutic non-compliance.

Methods

A qualitative review was undertaken by a literature search of the Medline database from 1970 to 2005 to identify studies evaluating the factors contributing to therapeutic non-compliance.

Results

A total of 102 articles was retrieved and used in the review from the 2095 articles identified by the literature review process. From the literature review, it would appear that the definition of therapeutic compliance is adequately resolved. The preliminary evaluation revealed a number of factors that contributed to therapeutic non-compliance. These factors could be categorized to patient-centered factors, therapy-related factors, social and economic factors, healthcare system factors, and disease factors. For some of these factors, the impact on compliance was not unequivocal, but for other factors, the impact was inconsistent and contradictory.

Conclusion

There are numerous studies on therapeutic noncompliance over the years. The factors related to compliance may be better categorized as “soft” and “hard” factors as the approach in countering their effects may differ. The review also highlights that the interaction of the various factors has not been studied systematically. Future studies need to address this interaction issue, as this may be crucial to reducing the level of non-compliance in general, and to enhancing the possibility of achieving the desired healthcare outcomes.

Adherence to medication in patients with dementia: predictors and strategies for improvement

Measures to facilitate patient medication adherence should be considered an integral part of the comprehensive care of older patients with multiple diseases. However, impairment of cognitive functions and dementia, in particular, may substantially compromise adherence behaviour. Therefore, a literature review was performed to identify factors associated with adherence to medication in patients with cognitive impairment or dementia, and to discuss strategies for improvement of non-adherence. Evidence-based information on how to deal with adherence to medication in patients with dementia is scarce because of a lack of specific studies. However, there is increasing knowledge about factors influencing medication adherence behaviour in older age, and emerging insight into the relationships between adherence behaviour and cognitive capacity, memory and executive function, in particular. Nevertheless, understanding elderly persons' strategies for maintaining regular use of even complex drug regimens is still limited. Progress of research in this field is needed. It is notable that measures to improve adherence consist of combinations of educational interventions and cognitive support but assessment of study participants' cognitive function is rare. In clinical practice, awareness of non-adherence as a result of cognitive impairment is relatively low. The most important step is early detection of cognitive impairment when this is impacting negatively on medication management. A practical geriatric screening test is recommended to identify memory problems and further functional impairments associated with cognitive impairment. Performance-based assessments might be useful for screening medication management capacity, in addition to a careful drug history, inspection of all medicines used (including over-the-counter drugs) and proxy information. However, no feasible screening methods have as yet found their way into clinical practice. Patients with impaired executive function, lack of awareness of illness and personality traits such as independency and high self-confidence may be at particular risk of non-adherence. The question is when to switch patient medication self-management to another person's responsibility if cognitive decline progresses. Further research is needed on measures to differentiate cognitive function and the relationships between memory concerns, memory strategy use and medication management. Also, studies evaluating the influence of personal support, health status and depression on the memory strategies used are needed. It is important to assess patients' attitudes toward medication and their relationship with proxies. Strategies for facilitating medication adherence in patients with dementia include prescribing as few medicines as possible, tailoring dose regimens to personal habits, and coordinating all drug dosing schedules as much as possible. When providing medication organizers, it is important to observe the patient's ability to use devices appropriately. In addition, automated computer-based reminding aids, online medication monitoring and telemonitoring may be helpful for patients with mild dementia. The decision as to when assistance with medication self-management is needed has to be made taking into account patient independency and safety aspects. This holds true for medicines with a narrow therapeutic range, in particular. Interactions among the individual patient's cognitive status, mood, level of self-efficacy and particular living situation must also be taken into consideration when searching for the optimal medication adherence strategy. No evidence-based recommendations can be given as yet. However, comprehensive assessment of the individual patient and careful consideration of all potential drug-related problems will probably help facilitate adherence and prevent compromised health outcomes in patients with dementia.

A qualitative exploration of multiple medicines beliefs in co-morbid diabetes and cardiovascular disease

AIM

Multiple medicines are typically prescribed for patients with Type 2 diabetes (T2D) and cardiovascular disease (CVD). Non-adherence to medicines can arise for those who self-manage the complex regimens typical of T2D and CVD. Perceptions about treatment and illness are probable drivers of adherence and self-management behaviours. However, few studies have explored perceptions about multiple medicines and none has examined the complexities of managing medicines used in T2D and CVD. We explored perceptions towards multiple medicines expressed by people managing co-morbid T2D and CVD.

METHOD

Nineteen adults managing multiple medicines for T2D and CVD participated in semi-structured interviews. The interviews were analysed using a modified grounded theory framework.

RESULTS

Participants were sceptical about the prescription of additional medicines, particularly CVD medicines. Often medicines for T2D management were thought to be more important than medicines prescribed for CVD management. Lifestyle change was thought to be a way of reducing CVD risk and this was related to the lower status given to CVD medication. Lipid-lowering medicines were often thought to be the least important CVD medication prescribed, with some participants considering cessation of medicines to test their necessity.

CONCLUSIONS

Despite evidence on the severity of macrovascular complications in T2D being available, participants in this study undervalued their CVD medications. Survey research is needed to assess how widely held these beliefs are and whether these beliefs influence non-adherence. Future research should explore how healthcare professionals can best address such beliefs.

Attitudes toward taking medication among outpatients with schizophrenia: cross-national comparison between Tokyo and Beijing

OBJECTIVES

The aim of this study was to compare attitudes toward medication and associated factors for patients with schizophrenia in Japan and China.

METHODS

Age-group matched samples were drawn from outpatients in Tokyo (N = 76) and Beijing (N = 76) according to the same inclusion/exclusion criteria. Psychotropic prescription and attitudes toward medication were measured using Drug Attitude Inventory-30 (DAI-30) and an original questionnaire regarding beliefs about psychiatric medication. Stepwise regression analysis of the DAI-30 data was performed for each group.

RESULTS

Japanese subjects were prescribed significantly larger amounts of antipsychotics. Polypharmacy of antipsychotics and concurrent use of anticholinergics, anxiolytics, or hypnotics were more frequently found among subjects in Tokyo than among those in Beijing. However, subjects in Tokyo and Beijing had similar subjective responses to medication, subjective evaluation of side-effects, and complaints about overuse of psychotropics. Subjects in Tokyo complained less about physician's over-reliance on medication and were less concerned about medication cost than those in Beijing. In Tokyo, longer duration of illness and lower subjective distress caused by side effects predicted a more positive subjective response, while female gender, younger age, and lower Brief Psychiatric Rating Scale score were independently correlated with a better subjective response in Beijing.

CONCLUSIONS

Subjective acceptance of multiple medications is greater for patients in Japan than those in China. Determinants of subjective response to medication varied between Japan and China.

A cross-cultural comparison of the developmental evolution of expertise in diabetes self-management

AIMS

The authors compare the findings of two research studies, one conducted in Japan and the other in Canada, about the developmental evolution of self-management of diabetes. In this article, the authors identify the similarities and differences that exist in the research data, proposing that the differences are situated in the different cultural perspectives of self-management that exist in both countries.

BACKGROUND

Researchers have acknowledged that self-management has cultural dimensions. Despite this, however, there are few studies that have provided a cross-cultural comparison of the experience of self-management among different cultural groups.

DESIGN

The authors conducted a critical comparative analysis of two models of developing expertise in diabetes self-management. The review included an analysis of the cultural meanings of the various terms and the underlying assumptions of both models.

CONCLUSIONS

The models shared many similarities; however, their differences were identified, such as the meaning and interpretation of various words or experiences, and shaped by the culturally bound perspectives of self and health.

RELEVANCE TO CLINICAL PRACTICE

The findings serve as a caution to imposing ethnocentric views and interpretations in diabetes care. In addition, they remind us about the importance of asking people with diabetes about what they understand, desire and understand. The findings challenge nurses to reflect on how the development of self-management of diabetes in various national contexts is influenced by health care practices that focus on control or harmony.

Comparison of individual perceptions of medication costs and benefits between intentional and unintentional medication non-adherence among Japanese patients

OBJECTIVE

To identify Japanese patients' perceptions of the costs and benefits of their medications by administering a questionnaire validated in Western patients and to compare the association between the perception levels and non-adherence to medication in the two non-adherent patient types, intentional, and unintentional.

METHODS

Japanese patients with chronic diseases were given a questionnaire and interviewed, and the validity and reliability of the scales generated were assessed. Logistic regression was used to analyse the association between individual perception levels and non-adherence to the medication regimen.

RESULTS

From 151 responses, two kinds of scales were generated following a report of Western patients; the necessity scale showed satisfactory reliability (Cronbach's alpha 0.79) but the concerns scale did not. Individual levels of perception of the necessity of medications were associated with unintentional non-adherence (the higher the level, the lower the odds ratio 1.0, 0.56, 0.40, and 0.15), while they were not associated with intentional non-adherence.

CONCLUSION

Japanese patients' perceptions of the benefits of medications, but not the costs were similar to those of Western patients, and these perceptions were likely to be different between intentionally and unintentionally non-adherent patients.

PRACTICE IMPLICATIONS

Strategies to improve non-adherence should be designed according to the non-adherent type.

Changes in attitudes among Japanese patients after Pharmacist Law revision

OBJECTIVE

To assess changes in patients' perception of their medications and their adherence to regimens after enactment of the Japanese Pharmacist Law revision of 1997, which stipulated provision of drug information to patients as one of the principal duties of pharmacists. Setting A university hospital in Japan.

METHOD

Comparison of cross sectional analyses between two time periods: shortly after enactment of the Pharmacist Law revision and about a half-decade later.

MAIN OUTCOME MEASURE

Patient's knowledge of the medications, anxiety level, individual beliefs regarding taking medications without anxiety, and adherence to the medication regimens.

RESULTS

There were 141 and 151 patients who participated during each period, respectively. The proportion of non-adherent patients significantly decreased from 68.8 to 53.6% (P = 0.008). Multiple logistic regression analysis indicated that the features of the intentionally non-adherent patients have changed; they have switched from persons who lack general comprehension about the medications (P = 0.01), ones who place an importance on knowing the side effects (P = 0.04), or who place no value on mutual reliance on their doctors (P = 0.03) into persons who place no value on understanding the purpose of taking their medications (P = 0.04) or who place value on multiple items to take medications without anxiety (P = 0.03), i.e., supposedly people who prefer thinking about their drug therapy from their own point of view based on comprehension of their disease and medications.

CONCLUSIONS

The rapid progression of drug information disclosure after enactment of the Pharmacist Law revision has likely resulted in drastic changes in patients' perception of their medications and led to improvements in medication adherence.

Physician strategies for addressing patient adherence to prescribed psychotropic medications in Japan: a qualitative study

BACKGROUND AND OBJECTIVES

Effective psychiatric care requires physicians to address the problems of patient adherence to prescribed medications. The aim of this study was to understand physician-perceived barriers to, and effective strategies for, prescribing anti-depressants in Japan.

METHODS

A qualitative study using semi-structured and key-informant interviews with a purposive sample of Japanese psychiatrists and key-informant physicians who had practiced in both the US and Japan.

RESULTS

Japanese psychiatrists recognize patient misperceptions, social stigma and resistance to acceptance of prescribed anti-depressant medication. Physicians also recognize that selective serotonin reuptake inhibitors (SSRIs) decrease rather than reinforce patient resistance. Physicians initially underdose, employ euphemisms and accept patient decisions to decline treatment by medication.

DISCUSSION

Even after the introduction of SSRI anti-depressants in 1999, Japanese psychiatrists' primary adherence strategy to initially underdose prescribed anti-depressants remains. The unstated physician strategy is to allow the pharmaceutical industry to address patient misperceptions, social stigma and the resistance to prescription therapies.

CONCLUSIONS

The results of this study delineate the fundamental strategies employed by Japanese physicians to address patient adherence to prescribed psychotropic medications, primarily to reduce the initial dose rather than to stress patient education.

Effect of personal and cultural beliefs on medication adherence in the elderly

Approximately 50% of patients across all age groups with varied types of medical conditions do not adhere to their prescribed medication regimens. Medication nonadherence is common in older adults who are often prescribed medications for age-related chronic disorders. The purpose of this paper is to investigate the effect of personal and cultural beliefs on older adults' medication adherence through a review of research studies published in journals across different disciplines. A systematic literature search using ten databases found 14 articles meeting the inclusion criteria. Belief-laden variables including self-efficacy (i.e. the belief that one can perform a specific behaviour under differing conditions), medication efficacy, confidence in the physician's knowledge, perceptions about natural products and home remedies, beliefs of control (over one's health), and illness perceptions were found to be significantly related to medication adherence among older adults. However, several measurement, design and sampling problems were identified in this review. The majority of the studies in the review evaluated older adults' medication adherence by self-report and used cross-sectional designs and convenience samples. Future studies should utilise prospective longitudinal designs and a more objective measure of medication adherence, such as electronic event monitoring, when examining factors related to older adults' medication adherence. Future research should also evaluate belief-related variables in larger and more ethnically diverse samples of older adults. Implications for assessment and intervention are evident from this literature review of the effect of personal and cultural beliefs on medication adherence in older adults.

Intentional and unintentional medication non-adherence: a comprehensive framework for clinical research and practice? A discussion paper

Non-adherence to medications is a prevalent and persistent healthcare problem, particularly for patients with a chronic disorder. Researchers have endeavoured to address poor adherence for the past five decades resulting in the accumulation of a vast body of literature. Despite the enormity of research conducted, interventions to date have neither been cost-effective nor predictably clinically effective in enhancing medication adherence. Though concerning, such contemporary information serves to refocus attention on the adequacy of knowledge regarding the factors influencing medication non-adherence. Although little consensus exists regarding the optimal categorisation of these influencing factors, increasingly, the broad and 'all encompassing' categorisation of intentional and unintentional factors is being used to account for patient medication-taking behaviours and actions. An extensive review of the related literature provides the basis for a critical discussion on the value and comprehensiveness of this current classification in guiding future adherence research and consequent clinical interventions. An appraisal of this categorisation is important if decisions regarding interventions are not to be made in a vacuum of insufficient understanding, which would result in the continued ineffective use and distribution of valuable resources to combat non-adherence.

Intentional and non-intentional non-adherence to medication amongst breast cancer patients

This study aimed to investigate the prevalence of and factors associated with non-adherence to medication amongst a sample of breast cancer patients. 131 women with stable disease were interviewed and completed standardised psychological measures. 55% of women reported non-adherence to medication frequently or occasionally, with younger women and those who disliked taking their medication being significantly less adherent (P = 0.015, P = 0.001). Women who deliberately omitted taking their tablets occasionally or frequently had significantly lower scores, indicative of a weaker influence, on 'internal' and 'powerful others' dimensions of health locus of control (P = 0.032, P = 0.009). Despite a life-threatening diagnosis, patients may not adhere to medication representing a potential missed opportunity for health gain and waste of resources. Furthermore, interpretation of clinical trial data may be misleading without adherence information. More research is needed to identify those at risk for non-adherence. If other routes of administration are available these options should be discussed with patients to maximise efficacy of therapy.