Reasons for non-adherence to cardiometabolic medications, and acceptability of an interactive voice response intervention in patients with hypertension and type 2 diabetes in primary care: a qualitative study

Perspective and Experience of Patients with Aplastic Anemia on Medication Adherence

Background

Drug treatment is critical for patients with aplastic anemia, and medication adherence directly impacts the therapeutic effect. Poor medication adherence is common among patients with chronic diseases. However, knowledge of the perceptions and experiences of patients with aplastic anemia regarding taking prescribed medicines is limited.

Objective

To gain insights into the perceptions and experiences of patients with aplastic anemia regarding taking prescribed medicines.

Methods

A descriptive qualitative design was used. Fifteen patients with aplastic anemia were recruited from the hematology department. Individual semi-structured interviews were conducted. The data were analyzed using the thematic analysis method and conceptualized using the Health Belief Model.

Results

Five themes emerged: the perceived threat of aplastic anemia, perceived benefits and barriers of taking prescribed medicines, cues to action, self-efficacy, and modifying factors. While patients' knowledge was limited, they acknowledged the threat of aplastic anemia and the necessity of drug treatments, but they also encountered some barriers in practice. The desire for health and healthcare providers' opinions were the main clues to medication adherence. The expectation of the future and the sense of self-competency made participants adopt good behavior.

Discussions

This study provided new perspectives on the medication adherence of patients with aplastic anemia, which may be valuable in clinical work and research. Further interventions should be developed for intentional and unintentional non-compliance. Future research can start with developing professional assessment tools addressing the influence of cognition and emotion on compliance.

Medication nonadherence: health impact, prevalence, correlates and interventions

Nonadherence to medicines is a global problem compromising health and economic outcomes for individuals and society. This article outlines how adherence is defined and measured, and examines the impact, prevalence and determinants of nonadherence. It also discusses how a psychosocial perspective can inform the development of interventions to optimise adherence and presents a series of recommendations for future research to overcome common limitations associated with the medication nonadherence literature. Nonadherence is best understood in terms of the interactions between an individual and a specific disease/treatment, within a social and environmental context. Adherence is a product of motivation and ability. Motivation comprises conscious decision-making processes but also from more 'instinctive', intuitive and habitual processes. Ability comprises the physical and psychological skills needed to adhere. Both motivation and ability are influenced by environmental and social factors which influence the opportunity to adhere as well as triggers or cues to actions which may be internal (e.g. experiencing symptoms) or external (e.g. receiving a reminder). Systematic reviews of adherence interventions show that effective solutions are elusive, partly because few have a strong theoretical basis. Adherence support targeted at the level of individuals will be more effective if it is tailored to address the specific perceptions (e.g. beliefs about illness and treatment) and practicalities (e.g. capability and resources) influencing individuals' motivation and ability to adhere.

Opinions on hypertension care and therapy adherence at the healthcare provider and healthcare system level: a qualitative study in the Hague, Netherlands

OBJECTIVES

Hypertension is a common cause of cardiovascular morbidity and mortality. Although hypertension can be effectively controlled by blood pressure-lowering drugs, uncontrolled blood pressure is common despite use of these medications. One explanation is therapy non-adherence. Therapy non-adherence can be addressed at the individual level, the level of the healthcare provider and at the healthcare system level. Since the latter two levels are often overlooked, we wished to explore facilitators and barriers on each of these levels in relation to hypertension care for people with hypertension, with a specific focus on therapy adherence.

DESIGN

Qualitative study using focus groups of healthcare providers. Data were analysed using the theoretical domains framework (TDF) and the behaviour change wheel.

SETTING AND PARTICIPANTS

Participants were from a highly urbanised city environment (the Hague, Netherlands), and included nine primary care physicians, six practice nurses and five secondary care physicians involved in hypertension care.

RESULTS

Nine domains on the TDF were found to be relevant at the healthcare provider level ('knowledge', 'physical, cognitive and interpersonal skills', 'memory, attention and decision processes', 'professional, social role and identity', 'optimism', 'beliefs about consequences', 'intention', 'emotion' and 'social influences') and two domains ('resources' and 'goals') were found to be relevant at the system level. Facilitators for these domains were good interpersonal skills, paying attention to behavioural factors such as medication use, and the belief that treatment improves health outcomes. Barriers were related to time, interdisciplinary collaboration, technical and financial issues, availability of blood pressure devices and education of people with hypertension.

CONCLUSIONS

This study highlighted a need for better collaboration between primary and secondary care, for more team-based care including pharmacists and social workers, tools to improve interpersonal skills and more time for patient-healthcare provider communication.

Patient and practitioner views on a combined face-to-face and digital intervention to support medication adherence in hypertension: a qualitative study within primary care

OBJECTIVES

To explore patients' and healthcare practitioners' (HCPs) views about non-adherence to hypertension medication and potential content of a combined very brief face-to-face discussion (VBI) and digital intervention (DI).

METHODS

A qualitative study (N=31): interviews with patients with hypertension (n=6) and HCPs (n=11) and four focus groups with patients with hypertension (n=14). Participants were recruited through general practices in Eastern England and London. Topic guides explored reasons for medication non-adherence and attitudes towards a potential intervention to support adherence. Stimuli to facilitate discussion included example SMS messages and smartphone app features, including mobile sensing. Analysis was informed methodologically by the constant comparative approach and theoretically by perceptions and practicalities approach.

RESULTS

Participants' overarching explanations for non-adherence were non-intentional (forgetting) and intentional (concerns about side effects, reluctance to medicate). These underpinned their views on intervention components: messages that targeted forgetting medication or obtaining prescriptions were considered more useful than messages providing information on consequences of non-adherence. Tailoring the DI to the individuals' needs, regarding timing and number of messages, was considered important for user engagement. Patients wanted control over the DI and information about data use associated with any location sensing. While the DI was considered limited in its potential to address intentional non-adherence, HCPs saw the potential for a VBI in addressing this gap, if conducted in a non-judgemental manner. Incorporating a VBI into routine primary care was considered feasible, provided it complemented existing GP practice software and HCPs received sufficient training.

CONCLUSIONS

A combined VBI-DI can potentially address intentional and non-intentional reasons for non-adherence to hypertension medication. For optimal engagement, recommendations from this work include a VBI conducted in a non-judgmental manner and focusing on non-intentional factors, followed by a DI that is easy-to-use, highly tailored and with provision of data privacy details about any sensing technology used.

Efficacy of Pharmaceutical Care in Patients with Type 2 Diabetes Mellitus and Hypertension: A Randomized Controlled Trial

BACKGROUND

The rates of treatment adherence and treat-to-target rates of blood pressure and blood glucose-related indexes in patients with hypertension and type 2 diabetes mellitus (T2DM) are associated with prognosis. This study aimed to investigate the efficacy of pharmaceutical care postdischarge for treatment adherence in hypertensive patients with type 2 diabetes mellitus (T2DM).

METHODS

This was a randomized controlled trial of patients with combined T2DM and hypertension treated between January and May 2018. Pharmaceutical care included free access to a clinical pharmacist, education material, a WeChat account for live discussion, and a telephone follow-up. The primary endpoint was the 3-month medication adherence. The secondary endpoints included the achieving levels of target rates and values of fasting plasma glucose (FPG), 2 h postprandial glucose (2hPG), and hemoglobin A1c (HbA1c) and the rates of reaching the achieving target rate of blood pressure target <130/80.

RESULTS

In 80 participants, the 3-month medication adherence was higher in the pharmaceutical care group than the routine group (90.0% vs. 52.5%, P < 0.001). In terms of FPG, 2hPG, and HbA1c, there were also significant differences between the pharmaceutical care and routine groups (FPG, 6.50 (6.00, 7.18) vs. 7.00 (6.83, 7.78) mmol/L, P=0.004; 2hPG, 8.45 (7.45, 9.28) vs. 9.35 (8.23, 10.15), P=0.007; HbA1c, 6.5% (6.3%, 7.0%) vs. 7.0% (6.5%, 7.4%), P=0.007). The achieving target rate of reaching the blood pressure target in the pharmaceutical care group (92.5%) was significantly higher than that in the routine group (62.5%; P < 0.05).

CONCLUSION

The postdischarge pharmaceutical care program in patients with T2DM and hypertension improves medication adherence.

Process Evaluation of MAPS: A Highly Tailored Digital Intervention to Support Medication Adherence in Primary Care Setting

Background: Medication adherence can prevent health risks, but many patients do not adhere to their prescribed treatment. Our recent trial found that a digital intervention was effective at improving medication adherence in non-adherent patients with Hypertension or Type 2 Diabetes; but we do not know how it brought about behavioural changes. This research is a post-trial process evaluation of the mechanism by which the intervention achieved its intended effects.

Methods: A mixed methods design with quantitative and qualitative evidence synthesis was employed. Data was generated by two studies. Study 1 used questionnaires to measure the underlying mechanisms of and the medication adherence behaviour, and digital logfiles to objectively capture intervention effects on the process of behaviour change. Multilevel regression analysis on 57 complete intervention group cases tested the effects of the intervention at modifying the mechanism of behaviour change and in turn at improving medication adherence. Study 2 used in depth interviews with a subsample of 20 intervention patients, and eight practise nurses. Thematic analysis provided evidence about the overarching intervention functions and recommendations to improve intervention reach and impact in primary care.

Results: Study 1 found that intervention effectiveness was significantly associated with positive changes in the underlying mechanisms of behaviour change (R² = 0.26, SE = 0.98, P = 0.00); and this effect was heightened twofold when the tailored intervention content and reporting on medication taking (R² = 0.59, SE = 0.74, P = 0.00) was interested into the regression model. Study 2 suggested that the intervention supported motivation and ability to adherence, although clinically meaningful effects would require very brief medication adherence risk appraisal and signposting to ongoing digitally delivered behavioural support during clinical consultations.

Conclusion: This post trial process evaluation used objective methods to capture the intervention effect on the mechanisms of behaviour change to explain intervention effectiveness, and subjective accounts to explore the circumstances under which these effects were achieved. The results of this process evaluation will inform a large scale randomised controlled trial in primary care.

Coordinating Healthcare with Artificial intelligence-supported Technology for Atrial Fibrillation patients (CHAT-AF): Protocol for a Randomised Controlled Trial (Preprint)

Background

Atrial fibrillation (AF) is an increasingly common chronic health condition for which integrated care that is multidisciplinary and patient-centric is recommended yet challenging to implement.

Objective

The aim of Coordinating Health Care With Artificial Intelligence–Supported Technology in AF is to evaluate the feasibility and potential efficacy of a digital intervention (AF-Support) comprising preprogrammed automated telephone calls (artificial intelligence conversational technology), SMS text messages, and emails, as well as an educational website, to support patients with AF in self-managing their condition and coordinate primary and secondary care follow-up.

Methods

Coordinating Health Care With Artificial Intelligence–Supported Technology in AF is a 6-month randomized controlled trial of adult patients with AF (n=385), who will be allocated in a ratio of 4:1 to AF-Support or usual care, with postintervention semistructured interviews. The primary outcome is AF-related quality of life, and the secondary outcomes include cardiovascular risk factors, outcomes, and health care use. The 4:1 allocation design enables a detailed examination of the feasibility, uptake, and process of the implementation of AF-Support. Participants with new or ongoing AF will be recruited from hospitals and specialist-led clinics in Sydney, New South Wales, Australia. AF-Support has been co-designed with clinicians, researchers, information technologists, and patients. Automated telephone calls will occur 7 times, with the first call triggered to commence 24 to 48 hours after enrollment. Calls follow a standard flow but are customized to vary depending on patients’ responses. Calls assess AF symptoms, and participants’ responses will trigger different system responses based on prespecified protocols, including the identification of red flags requiring escalation. Randomization will be performed electronically, and allocation concealment will be ensured. Because of the nature of this trial, only outcome assessors and data analysts will be blinded. For the primary outcome, groups will be compared using an analysis of covariance adjusted for corresponding baseline values. Randomized trial data analysis will be performed according to the intention-to-treat principle, and qualitative data will be thematically analyzed.

Results

Ethics approval was granted by the Western Sydney Local Health District Human Ethics Research Committee, and recruitment started in December 2020. As of December 2021, a total of 103 patients had been recruited.

Conclusions

This study will address the gap in knowledge with respect to the role of postdischarge digital care models for supporting patients with AF.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12621000174886; https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12621000174886

International Registered Report Identifier (IRRID)

DERR1-10.2196/34470

Trends in diabetes care and education by primary health care nurses in Auckland, New Zealand

AIMS

To examine trends in the management of patients with diabetes by primary health care nurses, its association with diabetes education and how valued and supported nurses feel in Auckland, New Zealand.

METHODS

Two representative cross-sectional surveys of all nurses providing community-based care, and patients with diabetes they consult, were conducted in 2006-8 and 2016. All participants completed a self-administered questionnaire on biographical details and a telephone interview on their provision of diabetes care.

RESULTS

Significantly more nurses discussed serum glucose and medications with patients, planned follow-up and scheduled practice nurse appointments in 2016 compared with 2006-8, and fewer specialist diabetologist appointments were made (12% versus 2%). Fewer nurses in 2016 than in 2006-8 felt valued (62% versus 75%) and supported (78% versus 89%) when managing patients (p-values = 0.0004). Nurses diabetes education was associated with recommended practice and feeling valued. Significantly more patients were prescribed metformin (81%) and insulin (46%) in 2016 compared with 58% and 30% in 2006-8. Despite this, HbA_1c levels remained unchanged.

CONCLUSIONS

Prescribed glycaemic-related medications increased, and more nurses engaged with patients about glycaemic control and medications in 2016 compared with 2006-8. Nurses undertaking diabetes education was strongly associated with best management practices and nurses feeling valued.

Arterial Stiffness, Cognitive Dysfunction and Adherence to Antihypertensive Agents. Is there a Link to Hypertensive Patients?

The incidence of hypertension (HTN) and its cardiovascular (CV) complications are increasing throughout the world. Blood pressure (BP) control remains unsatisfactory worldwide. Medical inertia and poor adherence to treatment are among the factors that can partially explain, why BP control rate remains low. The introduction of a method for measuring the degree of adherence to a given medication is now a prerequisite. Complex treatment regimes, inadequate tolerance and frequent replacements of pharmaceutical formulations are the most common causes of poor adherence. In contrast, the use of stable combinations of antihypertensive drugs leads to improved patient adherence. We aim to review the relationships between arterial stiffness, cognitive function and adherence to medication in patients with HTN. Large artery stiffening can lead to HTN. In turn, arterial stiffness induced by HTN is associated with an increased CV and stroke risk. In addition, HTN can induce disorders of brain microcirculation resulting in cognitive dysfunction. Interestingly, memory cognitive dysfunction leads to a reduced adherence to drug treatment. Compliance with antihypertensive treatment improves BP control and arterial stiffness indices. Early treatment of arterial stiffness is strongly recommended for enhanced cognitive function and increased adherence.

A Highly Tailored Text and Voice Messaging Intervention to Improve Medication Adherence in Patients With Either or Both Hypertension and Type 2 Diabetes in a UK Primary Care Setting: Feasibility Randomized Controlled Trial of Clinical Effectiveness

Background

The efficacy of a highly tailored digital intervention to support medication adherence and feasibility to support clinical effectiveness as an adjunct to the primary care setting has not been evaluated.

Objective

This trial aimed to assess the behavioral efficacy of a highly tailored digital intervention to support medication adherence and to evaluate the feasibility of its clinical effectiveness, in patients with either or both hypertension and type 2 diabetes. We also examined quality of life and mechanisms of behavior change. Intervention fidelity, engagement, and satisfaction were also explored.

Methods

This was a multicenter, individually randomized controlled trial of 2 parallel groups: an intervention group that received a highly tailored text message and interactive voice response intervention for 12 weeks, and a control group that received usual care. Medication adherence was measured using self-reports and assessor-blinded practice records of a repeat prescription. Systolic blood pressure and glucose levels were assessed by nurses blinded to group allocation during practice visits at 3 months follow-up. Questionnaires obtained data to assess intervention mechanisms of action and satisfaction and digital log files captured data to evaluate fidelity and engagement.

Results

A total of 135 nonadherent patients (62/135, 46% female; 122/135, 90.3%; aged above 50 years) were randomly allocated in the intervention (n=79) or in the control group (n=56); of whom 13% (18/135) were lost at follow-up. Medication adherence was significantly improved in the intervention group compared with the control group (t₁₁₆=2.27; P=.02, 2-tailed). Systolic blood pressure was 0.6 mmHg (95% CI −7.423 to 6.301), and hemoglobin A_1c was 4.5 mmol/mol (95% CI −13.099 to 4.710) lower in the intervention group compared with the control group. Changes in intentional nonadherence and nonintentional nonadherence explained the improvements in medication adherence in the intervention group (beta=.074, SE=0.464; P=.04), but not in the control group (beta=.00, SE 1.35; P=.37). The intervention had 100% fidelity, a median of 12 days of engagement, and 76% overall satisfaction.

Conclusions

Our trial is the first that has been conducted in the United Kingdom and showed that among nonadherent patients with either or both hypertension and type 2 diabetes, a highly tailored digital intervention was effective at improving treatment adherence and feasible to obtain clinically meaningful outcomes. Changes in intentional and nonintentional nonadherence predicted the improvements in medication adherence. The intervention had high fidelity, engagement, and satisfaction. Future research using a rigorous design is needed to evaluate the clinical effectiveness and cost-effectiveness of the intervention in primary care.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN) 10668149; http://www.controlled-trials.com/ISRCTN10668149.

Medication adherence in the older adults with chronic multimorbidity: a systematic review of qualitative studies on patient's experience

PURPOSE

Medication non-adherence represents a socially relevant challenge, particularly when interlinked to multiple chronic diseases and polypharmacy. Non-adherence rates affect treatment efficacy and increase health care costs. The aim of the study was to identify factors influencing medication adherence in the older adults through a systematic review of qualitative studies on patients' experience.

METHODS

Two electronic databases were searched for qualitative studies on medication adherence in chronic diseases (hypertension, heart disease, COPD, asthma) involving people aged 65 + . The systematic review was performed according to the PRISMA statement guidelines, employing theoretical frameworks of the ABC Taxonomy of patient adherence and Three Factor model of determinants of behaviour.

RESULTS

The initial database search identified 1234 records, of which 39 studies were considered eligible. Most of the studies focused on hypertension and were conducted in English-speaking countries. According to the ABC Taxonomy, Persistence and Implementation were the most often considered phases. Considering the Three Factor model, the most often reported themes were Information and Strategies upon being adherent. Stemming from the review findings and the patients' narratives, a new integrated model was proposed. It reports the patient's decisional flowchart describing barriers and facilitators (personal, social and environmental) to adherence.

CONCLUSION

Medication adherence is a complex and multifaceted process. The implementation of theoretical frameworks along with a patient-centred perspective may provide clinicians with useful suggestions for clinical practice, enhancing the patient's ability to adhere.

Evaluation of the primary care for chronic diseases in the high coverage context of the Family Health Strategy

BACKGROUND

This cross-sectional study evaluated the adequacy of the Family Health Strategy for the primary care model for chronic noncommunicable diseases and the changes that occurred between the two cycles of external evaluations of the National Program for Improving Access and Quality of Primary Care, which took place in 2012 and 2014, in the higher coverage context of the Family Health Strategy of Brazil, in the state of Tocantins, Brazil.

METHODS

The data source contained information on the infrastructure of the 233 Primary Health Units and on the work process of 266 health teams. The Principal Component Analysis for Categorical Data technique and the McNemar chi-squared statistical test for comparing paired samples were used, and a significance level of 5% with a 95% Confidence Interval was used.

RESULTS

The analysis identified a low proportion of dispensing of medications for the treatment of chronic disease in both cycles. There was a significant increase in seasonal influenza vaccination, in the number of sterilization, procedure, dressings and inhalation rooms. There was a small but significant reduction in the materials for cervical cancer screening, although they are available in almost 90.0% of the PHUs. More than 70.0% of the health teams carried out additional health education activities, encouraged physical activity, registered schoolchildren with health needs for monitoring, evaluated user satisfaction and user referral.

CONCLUSIONS

The findings of this study highlighted the improvement of the structure of the Primary Health Units, but identified a low provision of medicines to treat chronic diseases. The health promotion was performed as the main work process tool of family health teams, but it was little focused on intersectoral actions and on actions with the population in the area or on the empowerment of users through self-management support for chronic diseases. Furthermore, it is critical that the Family Health Strategy in Tocantins be organized and focused on the care of chronic diseases to improve and adapt itself to a primary chronic care model.

Comparison of an interactive voice response system and smartphone application in the identification of gout flares

OBJECTIVE

To examine the feasibility, preference, and satisfaction of an interactive voice response (IVR) system versus a customized smartphone application (StudyBuddy) to capture gout flares METHODS: In this 24-week prospective, randomized, crossover, open-label pilot study, 44 gout patients were randomized to IVR vs. StudyBuddy and were crossed over to the other technology after 12 weeks. Flares were reported via weekly (and later daily) scheduled StudyBuddy or IVR queries. Feasibility was ascertained via response rate to scheduled queries. At 12 and 24 weeks, participants completed preference/satisfaction surveys. Preference and satisfaction were assessed using dichotomous or ordinal questions. Sensitivity was assessed by the frequency of flare reporting with each approach.

RESULTS

Thirty-eight of 44 participants completed the study. Among completers, feasibility was similar for IVR (81%) and StudyBuddy (80%). Conversely, most (74%) preferred StudyBuddy. Measures of satisfaction (ease of use, preference over in-person clinic visits, and willingness for future use) were similar between the IVR and StudyBuddy; however, more participants deemed the StudyBuddy as convenient (95% vs. 73%, P = 0.01) and less disruptive (97% vs. 82%, P = 0.03). Although the per patient number of weeks in flare was not significantly different (mean 3.4 vs. 2.6 weeks/patient, P = 0.15), the StudyBuddy captured more of the total flare weeks (35%) than IVR (27%, P = 0.02).

CONCLUSION

A smartphone application and IVR demonstrated similar feasibility but overall sensitivity to capture gout flares and participant preference were greater for the smartphone application. Participant preference for the smartphone application appeared to relate to perceptions of greater convenience and lower disruption.

TRIAL REGISTRATION

NCT, NCT02855437 . Registered 4 August 2016.

Effect of an interactive voice response system on self-management in kidney transplant recipients: Protocol for a randomized controlled trial

INTRODUCTION

Adherence to a complex and ongoing set of therapeutic recommendations significantly determines short and long-term outcomes after kidney transplantation (KT). Interactive voice response system (IVRS) is a novel phone-based platform which is potentially useful to deliver health behavior interventions.

OBJECTIVE

The aims of the study is to describe the development of a theory-driven and educational IVRS investigate the effect of an IVRS on the self-management outcomes in KT recipients as compared with the control group.

METHODS

This study has been designed as a randomized, 2 parallel groups controlled trial. The KT recipients' older than18 years of age with access to a cellphone will be included. A total of 120 patients will be randomly assigned to the control and intervention groups. The participants in the intervention group will receive completely automatic calls in 3 categories: educational, medication adherence, and reminders by the IVRS, whereas those in the control group will receive usual care. The follow up will be performed within 6 months. The primary outcome will be the medication adherence while patients' transplant knowledge, health-related quality of life, and rehospitalization rates will be considered as secondary outcomes.

RESULTS

Thus far, recruitment of participants has not been completed and results will be published in 2019.

DISCUSSION

The IVRS is potentially useful to help KT recipients improve the self-management outcomes. The hypothesis is using an IVRS intervention makes a significant difference between basel assessment of adherence to immunosuppressive medications scale, 12-item short form survey, second version, kidney transplant understanding tool baseline scores, and those obtained at the end of study.

TRIAL REGISTRATION NUMBER

This trial is registered with the Iran Trial Registrar under registration number IRCT20180124038492N1 and registration date 30 January 2018. https://irct.ir/trial/29215.

Development and piloting of a highly tailored digital intervention to support adherence to antihypertensive medications as an adjunct to primary care consultations

OBJECTIVES

This paper describes the systematic development and piloting of a highly tailored text and voice message intervention to increase adherence to medication in primary care.

METHODS

Following the Medical Research Council guidance, this paper describes (a) the systematic development of the theoretical framework, based on review of theories and meta-analyses of effectiveness; (b) the systematic development of the delivery mode, intervention content and implementation procedures, based on consultations, face-to-face interviews, think-aloud protocols, focus groups, systematic reviews, patient and public involvement/engagement input, intervention pre-test; and (c) the piloting of the intervention, based on a 1-month intervention; and follow-up assessment including interviews and questionnaires. The mixed-methods analysis combined findings from the parallel studies complementarily.

RESULTS

intervention development suggested the target behaviour of the intervention should be the tablets taken at a regular time of the day. It recommended that patients could be more receptive to intervention content when they initiate medication taking or they change prescription plan; and more emphasis is needed to patients' consent process. Intervention piloting suggested high intervention engagement with, and fidelity of, the intervention content; which included a combination of behaviour change techniques, and was highly tailored to patients' beliefs and prescription plan. Patients reported that the intervention content increased awareness about the necessity to take and maintain adherent to medication, reinforced social support and habit formation, and reminded them to take medication as prescribed.

CONCLUSION

Tailored automated text and voice message interventions are feasible ways to improve medication adherence as an adjunct to primary care.

TRIAL REGISTRATION NUMBER

ISRCTN10668149.

Supporting Adherence to Medicines for Long-Term Conditions

Abstract. Pharmaceutical prescriptions are core to the treatment of most chronic illnesses, yet only half are taken as prescribed. Despite the high costs of nonadherence to individuals and society, effective adherence-promoting interventions are elusive. This is partly due to the sheer complicity of the issue. There are numerous determinants of adherence, both internal to the patient (intrinsic) and external (extrinsic, e.g., environmental or health system-related factors). Also, the relative importance of these determinants varies between individuals and even within the same individual over time and across treatments, presenting a challenge for intervention design. One complication is that interventions can target several levels: (1) patient (e.g., enhancing motivation and/or ability to adhere), (2) patient-provider interactions (e.g., improving communication and the prescribing process), and (3) the healthcare system (e.g., providing the opportunity to access medication through regulatory approval and co-payment schemes). Here, we focus on level 1: the patient. Although environmental factors are important, the effect of an intervention designed to change them will depend on how they impact on the individual. We describe the Perceptions and Practicalities Approach (PAPA), a pragmatic framework positing that adherence/nonadherence is essentially a produce of individual motivation and ability. Adherence interventions, targeted at any level, will therefore be more effective if tailored to address the perceptions and practicalities underpinning individual motivation and ability. We discuss how PAPA can be operationalized, including the application of theoretical models of illness and treatment representation (Necessity-Concerns Framework and Leventhal’s Common-Sense Model) to address salient adherence-related perceptions.

Factors Associated With Medication Adherence In Elderly Retired Outpatients In São Paulo, Brazil

OBJECTIVE

To evaluate medication adherence and associated socioeconomic factors in elderly Brazilians.

METHODOLOGY

This observational study was conducted with 159 elderly retired in an outpatient clinic in the city of São Paulo. Treatment adherence was assessed with the questions from the Morisky Green Levine Medication Adherence Questionnaire, and medications were classified using the Anatomical Therapeutic Chemical system. Statistical tests and adjusted Poisson regression models were used to analyze variables.

RESULTS

The study population was mostly female (67.5%), had an average age of, and took an average of 6.5 medications per day. The most commonly used drugs were agents acting on the renin-angiotensin system (67.9%), statins (62.3%), antithrombotic agents (48.4%), and biguanides (37.1%) for the treatment of hypertension (76.7%), dyslipidemia (54.1%), and diabetes (47.8%). The rate of adherence was below 60% in the groups of participants that were analyzed except for the high household income category, which had a rate of 75.8%.

CONCLUSION

Medication adherence among the elderly was low in all categories except for the high household income category, a relevant finding that will help to understand medication adherence patterns in elderly Brazilians.

Acceptability of the Medication Adherence for Patients Support intervention to improve adherence to patients prescribed medications for hypertension or comorbidities, as an adjunct to primary care: A qualitative study

Tailored interventions delivered via text and voice messages can improve adherence to multiple medications. However, no such intervention has been developed in the UK primary-care setting. We conducted focus groups with 12 patients with hypertension, type 2 diabetes, or both conditions, presumed to be non-adherent and recruited from deprived neighborhoods, to assess the acceptability and inform the development of an intervention to provide ongoing support for adherence, as an adjunct to primary-care consultations. Patients recommended ways to improve the tailored content and delivery of the intervention; like highly interactive messages to report both medication taking and determinants of medication adherence.

Interactive voice response interventions targeting behaviour change: a systematic literature review with meta-analysis and meta-regression

OBJECTIVE

A number of promising automated behaviour change interventions have been developed using advanced phone technology. This paper reviewed the effectiveness of interactive voice response (IVR)-based interventions designed to promote changes in specific health behaviours.

METHODS

A systematic literature review of papers published between January 1990 and September 2017 in MEDLINE, CINAHL, Embase, PsycINFO, SCOPUS and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted. From the total of 2546 papers identified, 15 randomised control trials (RCTs) met the eligibility criteria and were included in a random effects meta-analysis. Meta-regression analysis was used to explore whether behaviour change techniques (BCTs) that were used in the interventions were associated with intervention effectiveness.

RESULTS

Meta-analysis of 15 RCTs showed that IVR-based interventions had small but significant effects on promoting medication adherence (OR=1.527, 95% CI 1.207 to 1.932, k=9, p=0.000) and physical activity (Hedges' g=0.254, 95% CI 0.068 to 0.439, k=3, p=0.007). No effects were found for alcohol (Hedges' g=-0.077, 95% CI -0.162 to 0.007, k=4, p=0.073) or diet (Hedges' g=0.130, 95% CI -0.088 to 0.347, k=2, p=0.242). In the medication adherence studies, multivariable meta-regression including six BCTs explained 100% of the observed variance in effect size, but only the BCT 'information about health consequences' was significantly associated with effect size (β=0.690, SE=0.199, 95% CI 0.29 to 1.08, p=0.000).

CONCLUSION

IVR-based interventions appear promising in changing specific health behaviours, such as medication adherence and physical activity. However, more studies are needed to elucidate further the combination of active components of IVR interventions that make them effective and test their feasibility and effectiveness using robust designs and objective outcome measures.

Automated telecommunication interventions to promote adherence to cardio-metabolic medications: meta-analysis of effectiveness and meta-regression of behaviour change techniques

Automated telecommunication interventions, including short message service and interactive voice response, are increasingly being used to promote adherence to medications prescribed for cardio-metabolic conditions. This systematic review aimed to comprehensively assess the effectiveness of such interventions to support medication adherence, and to identify the behaviour change techniques (BCTs) and other intervention characteristics that are positively associated with greater intervention effectiveness. Meta-analysis of 17 randomised controlled trials showed a small but statistically significant effect on medication adherence, OR = 1.89, 95% CI [1.51, 2.36], I² = 89%, N = 25,101. Multivariable meta-regression analysis including eight BCTs explained 88% of the observed variance in effect size (ES). The BCTs 'tailored' and 'information about health consequences' were positively and significantly associated with ES. Future studies could explore whether the inclusion of these and/or additional techniques (e.g., 'implementation intentions') would increase the effect of automated telecommunication interventions, using rigorous designs and objective outcome measures.