Patient and healthcare provider perspectives on adherence with antihypertensive medications: an exploratory qualitative study in Tanzania

Adherence to pharmacological therapy for hypertension in Portugal: a health professionals focus groups study

INTRODUCTION

The perspectives of local healthcare professionals for developing effective strategies to enhance medication adherence in arterial Hypertension as well as its barriers have not yet been explored through qualitative research in Portugal.

OBJECTIVES

This study aimed to assess the views of healthcare professionals including general practitioners/family physicians, nurses, and community pharmacists, from Portugal on effective strategies to improve medication adherence in Hypertension, and to identify factors hindering pharmacological adherence.

METHODS AND ANALYSES

This was a qualitative study with synchronous online focus groups, in which, the participants were general practitioners/family physicians, family nurses, or community pharmacists in Portugal with experience managing patients with Hypertension. They were selected based on age, sex, and geographical region with the number of focus groups determined by theoretical saturation. Recruitment was facilitated through specific mailing lists. Purposive and snowball sampling techniques were employed. Focus group discussions were recorded and transcribed. Two researchers conducted content analyses via MAXQDA®2023, applying comparative analysis and reaching consensus. The results are described narratively.

RESULTS

Three focus group discussions revealed a multifaceted approach to improving medication adherence for Hypertension. Key strategies to enhance coordination and communication among healthcare professionals, patients, and caregivers were identified. These included shared informatics software among healthcare professionals; using mobile applications and wearables; health literacy initiatives and patient empowerment; preprepared medication in pillboxes; involving family and the concept of a "family pharmacist". Participants highlighted barriers to medication adherence such as the lack of communication with patients concerning issues like medication adherence.

CONCLUSIONS

This qualitative study outlines strategies to improve medication adherence among patients with Hypertension in Portugal. These involve improving healthcare coordination and communication, patient empowerment, and involving family and "family pharmacists" in supporting adherence. These strategies are based on the insights of healthcare professionals and could be implemented following robust intervention studies.

CLINICAL TRIAL NUMBER

Not applicable.

Tensions in caring for chronic patients' medication adherence: A qualitative study in Cyprus

Medication adherence (MA) to recommended treatment is a multi-faceted problem and an ongoing challenge for healthcare providers (HCPs) to monitor. This qualitative study with 10 HCPs in Cyprus aims to explore HCPs' perceptions and strategies used on addressing medication non-adherence (MNA) in patients with chronic conditions. Two main themes emerged from the analysis reflecting the ways that HCPs described their reactions to MNA of their patients: (1) "Relying on information provision to improve MA" and (2) "Trying to understand patients' perspective." HCPs reported empathizing with patients and engaging in discussions to understand patients' perspective and reasons for MNA, so as to explore alternative solutions. Simultaneously, some HCPs reflected that the techniques used to improve MA are solely centered around information on medication and side-effects. HCPs experienced an internal conflict between providing patient-centered care versus using directive approaches to improve MA. Findings suggest how HCPs could thoroughly address patients' individual barriers.

Exploring patient's perspective of barriers to diabetic medication adherence in Jazan, Saudi Arabia, using the social determinants of health model

Background

Type 2 diabetes mellitus is usually associated with long-term macrovascular and microvascular complications that negatively impact the patient's quality of life and add economic burden to the healthcare system. Understanding patients' perspectives on medication nonadherence is essential for planning the appropriate methods and strategies to improve medication adherence among patients with uncontrolled diabetes.

Aim

Therefore, this study aims to explore patients' perceptions of the barriers to medication adherence through the Social Health determinants framework.

Method

After obtaining ethical approval, qualitative face-to-face interviews with a sample of patients with type 2 diabetes mellitus (uncontrolled diabetes) were conducted. Interviews were audio-recorded, and then the data were analyzed using thematic analysis to identify essential themes related to the patient's views.

Results

Fifteen patients with type 2 diabetes mellitus were interviewed. Potential barriers to antidiabetic medications were identified and categorized based on the Social Determinants of Health domains. The patient's health perceptions and behaviors were found to positively or negatively impact medication adherence. Beliefs toward antidiabetic medications, polypharmacy, medication-related problems, and the relationship between patients and their healthcare providers that related to healthcare access and quality domains were also reported as potential barriers to medications. Financial constraints, social stigma, and family support were other social health determinants factors that were found to have either positive or negative impacts on adherence. Nevertheless, using mobile health applications was suggested to facilitate medication adherence.

Conclusion

Social Determinants of Health, such as education about type 2 diabetes mellitus, quality and access to healthcare, and social stigma and support, might significantly affect medication adherence among type 2 diabetes mellitus patients. This study's findings can aid the development of suitable patient-specific tools and strategies to enhance medication adherence.

Managing diabetes and hypertension in western Kenya: A qualitative study of experiences of patients supported by the primary health integrated care for chronic conditions (PIC4C) model of care

The Primary Health Integrated Care for Chronic Conditions (PIC4C) pilot project was launched in 2018 to strengthen prevention and control of four non-communicable conditions at primary health care level in western Kenya. We conducted a qualitative study to explore the extent to which PIC4C integrated services supported people with hypertension and/or diabetes towards timely diagnosis and referral, treatment, follow-up and adherence, from the perspective of those receiving care. Semi-structured interviews were conducted with a purposively sampled patient cohort at two time points, with the intention of capturing changes over time (total (n) = 43, completion of both interviews (n) = 37). We extracted existing survey data to describe socio-demographic characteristics and analyzed qualitative data thematically. We identified two cross-cutting contextual factors, individual's financial resources and their social situation, which shaped each stage of their interactions with PIC4C services. The PIC4C model successfully engaged people in accessing screening services to enable timely diagnosis and referred them to enter care. Free community level screening services and decentralization of care to lower level facilities reduced cost barriers for patients. However, retention in care and adherence to treatment were affected by the wider system context in which PIC4C was operating, including inconsistencies in medication availability and patients' limited financial capacity. Individually tailored advice from health care workers to work around some of these challenges supported self-management strategies. Further development of the service should focus on supporting health care workers to adopt flexible, contextually responsive approaches in order to support patients facing economic and other constraints to engage in (self) care.

Barriers and Facilitators of Medication Adherence in Hypertension Patients: A Meta-Integration of Qualitative Research

The aim of this qualitative systematic review is to analyze the barriers and facilitators to the uptake of antihypertensive medication in hypertensive patients. The databases of PubMed, Embase, Web of Science, CINAHL, Cochrane Library, MEDLINE, China National Knowledge Infrastructure, Wanfang, VIP, and Chinese Biomedical were searched from inception to June 2023. The studies were screened, extracted, and assessed independently by two researchers. Previously, the researchers used the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research to assess the quality of the included studies. A total of 27 studies were considered, resulting in two combined findings: a good level of knowledge, belief, and behavior and adequate social support were facilitators of medication adherence in hypertensive patients. In contrast, lack of medication literacy, difficulty adapting to roles, reduced sense of benefit from treatment, limited access to healthcare resources, and unintentional nonadherence were barriers. Medication adherence in hypertensive patients remains a challenge to be addressed. Future research should explore how complex interventions using a combination of evidence-based strategies and targeting multiple adherence behaviors (eg, long-term adherence to medication) are effective in improving medication adherence.

Utilizing Social Determinants of Health Model to Understand Barriers to Medication Adherence in Patients with Ischemic Stroke: A Systematic Review

Introduction

Ischemic strokes and their recurrence create an immense disease burden globally. Therefore, preventing recurrent strokes by promoting medication adherence is crucial to reduce morbidity and mortality. In addition, understanding the barriers to medication adherence related to the social determinants of health (SDoH) could promote equity among persons with ischemic stroke.

Objective

To explore the barriers to medication adherence among patients with ischemic stroke through the SDoH.

Methods

This systematic review included studies published between January 2018 and December 2022 identified through PubMed, MEDLINE, Web of Science, and CINAHL Plus Full Text. The descriptions of the studies were systematically summarized and discussed based on the SDoH from the US Healthy People 2030 initiative.

Results

Eight studies met the inclusion criteria and were included in this review. The most common barrier to adherence was inappropriate medication beliefs, medication side effects, and patient-physician relationship, which relate to the dimensions of healthcare access and quality. Health literacy and health perception, dependent on education access and quality, frequently influenced adherence. Other social determinants, such as financial strain and social and community context, were found to alter adherence behaviors. No study addressed the neighborhood and built environment domain. We found that cognitive impairment is another factor that impacts adherence outcomes among stroke patients.

Conclusion

Multifaceted approaches are needed to address the SDoH to improve medication adherence among patients with ischemic stroke. This review emphasized strategies, including patient education, provider-patient communication, social support, health literacy, technology, and policy advocacy to enhance adherence.

Stakeholder's perspectives on acceptable interventions for promoting hypertension medication adherence in Namibia: nominal group technique

OBJECTIVE

To determine the most acceptable hypertension intervention package to promote hypertension adherence based on stakeholders' perspectives.

DESIGN

We employed the nominal group technique method and purposively sampled and invited key stakeholders offering hypertension services and patients with hypertension. Phase 1 was focused on determining barriers to hypertension adherence, phase 2 on enablers and phase 3 on the strategies. We employed the ranking method based on a maximum of 60 scores to establish consensus regarding hypertension adherence barriers, enablers and proposed strategies.

SETTING AND PARTICIPANTS

12 key stakeholders were identified and invited to participate in the workshop in Khomas region. Key stakeholders included subject matter experts in non-communicable diseases, family medicine and representatives of our target population (hypertensive patients).

RESULTS

The stakeholders reported 14 factors as barriers and enablers to hypertension adherence. The most important barriers were: lack of knowledge on hypertension (57 scores), unavailability of drugs (55 scores) and lack of social support (49 scores). Patient education emerged as the most important enabler (57 scores), availability of drugs emerged second (53 scores) and third having a support system (47 scores). Strategies were 17 and ranked as follows: continuous patient education as the most desirable (54 scores) strategy to help promote hypertension adherence, followed by developing a national dashboard to primarily monitor stock (52 scores) and community support groups for peer counselling (49 scores).

CONCLUSIONS

Multifaceted educational intervention package targeting patient and healthcare system factors may be considered in implementing Namibia's most acceptable hypertension package. These findings will offer an opportunity to promote adherence to hypertension therapy and reduce cardiovascular outcomes. We recommend a follow-up study to evaluate the proposed adherence package's feasibility.

Care cascades for hypertension and diabetes: Cross-sectional evaluation of rural districts in Tanzania

BACKGROUND

Noncommunicable diseases (NCDs), especially hypertension and diabetes, are rapidly rising in sub-Saharan Africa, necessitating health systems transformations. In Tanzania, current policies aim to improve control of hypertension and diabetes, but information is still needed to assess the gaps in treatment.

METHODS AND FINDINGS

We conducted a cross-sectional household survey of 784 adults in two districts in Tanzania from December 2020 to January 2021, capturing the cascade-of-care for hypertension and diabetes. The ages of the respondents ranged from 18 to 89 years. Of those screened positive for these conditions, we measured the proportion in each step of the cascades: awareness, care engagement, treatment, and control. We conducted multivariable logistic regression analyses for all four steps along the hypertension care cascade with the independent variables of social health protection schemes, and prior diagnosis of comorbid diabetes, and demographic information. In our sample, of the 771 who had their blood pressure measured, 41% (95% confidence interval (CI): 38% to 44%) were screened positive for hypertension, and of the 707 who had their blood sugar measured, 6% (95% CI: 4% to 8%) were screened positive for diabetes. Of those with hypertension, 43% (95% CI: 38% to 49%) had a prior diagnosis, 25% (95% CI: 21% to 31%) were engaged in care, 21% (95% CI: 3% to 25%) were on treatment, and 11% (95% CI: 8% to 15%) were controlled. Of the 42 respondents with diabetes, 80% (95% CI: 69% to 93%) had a prior diagnosis. The diabetes care cascade had much less drop-off, so 66% of those with diabetes (95% CI: 52% to 82%) were engaged in care and on treatment, and 48% (95% CI: 32% to 63%) had their diabetes controlled at the point of testing. Healthcare fee exemptions were independently associated with higher odds of being previously diagnosed (OR 5.81; 95% CI [1.98 to 17.10] p < 0.005), engaged in care (OR 4.71; 95% CI [1.59 to 13.90] p 0.005), and retained in treatment (OR 2.93; 95% CI [1.03 to 8.35] p < 0.05). Prior diagnosis of comorbid diabetes was highly associated with higher odds of being engaged in care for hypertension (OR 3.26; 95% CI [1.39 to 7.63] p < 0.005). The two primary limitations of this study were reliance on screening at a single time point only of people available at the village at the time of the sample and dependence on self-report for to inform the three cascade steps of prior diagnosis, healthcare visits for engagement in care, and treatment use.

CONCLUSIONS

The high burden of hypertension and low levels of control in our study underscores the importance of improving the awareness and treatment of hypertension. The differences in the care cascades for hypertension and diabetes demonstrates that chronic NCD treatment is possible in this setting, but efforts will be needed across the entire care cascade to improve hypertension control.

Effectiveness of instructional videos for enhancing healthcare provider competencies for hypertension management - a pre-post study in primary healthcare settings, Tanzania

Background

Inadequate adherence to hypertension (HT) clinical standards by healthcare providers is one of the major barriers for HT management. We examined the effectiveness of four short instructional training videos on HT management.

Methods

Eighteen primary health care facilities were randomly selected using systematic sampling from five districts in the Dar es Salaam region, Tanzania. Pre-post provider knowledge assessments were conducted six months after training and provider performance was measured using patient observations on 8-10 consecutive adult patients per facility. A Screening Quality Index (SQI), comprised of ten HT screening standards, was used to measure adherence.

Results

Pre-post knowledge scores improved significantly, for, time between blood pressure (BP) readings (28.1% to 72.7%, p=0.01), BP threshold for patients with complications (21.2% to 97.0%, p<0.001), and lifestyle/dietary counseling (from 36.4% to 97.0%, p<0.001). SQI was significantly higher following the training for all provider groups; Nurses (3.0±3.5 to 8.4±1.0, p<0.001), Assistant Medical Officers and Medical Officers (3.5±4.1 to 7.6±2.4, p<0.001), and Assistant Clinical Officers and Clinical Officers (5.4±3.8 to 8.4±2.0, p<0.001). After training, significantly higher adherence was evident for key aspects of managing patients with HT: e.g., counseling on medication (62.1% to 92.7%, p=0.002), side effects (41.4% to 56.1%, p=0.009), reducing caloric intake (69.0 % to 95.1%, p=0.003), reducing cooking salt (65.5% to 97.6%, p<0.01), increasing physical activity (55.2% to 92.7% p<0.001), stopping/reducing cigarette smoking (24.1% to 63.4%, p=0.001), and reducing alcohol consumption (24.1% to 68.3%, p<0.001). SQI was significantly associated with number of years of provider experience (more than 2 years), type of primary healthcare facility (public facility), and exposure to the training intervention.

Conclusion

Training with short instructional videos can improve provider competency and clinical performance for HT management. The strategy has the potential to enhance effective implementation of HT control strategies in primary care clinics in Tanzania and elsewhere.

Patient and Provider Perspectives on Medication Non-adherence Among Patients with Depression and/or Diabetes in Diverse Community Settings - A Qualitative Analysis

BACKGROUND

Diabetes and depression affect a significant percentage of the world's total population, and the management of these conditions is critical for reducing the global burden of disease. Medication adherence is crucial for improving diabetes and depression outcomes, and research is needed to elucidate barriers to medication adherence, including the intentionality of non-adherence, to intervene effectively. The purpose of this study was to explore the perspectives of patients and health care providers on intentional and unintentional medication adherence among patients with depression and diabetes through a series of focus groups conducted across clinical settings in a large urban area.

METHODS

This qualitative study utilized a grounded theory approach to thematically analyze qualitative data using the framework method. Four focus groups in total were conducted, two with patients and two with providers, over a one-year period using a semi-structured facilitation instrument containing open-ended questions about experiences, perceptions and beliefs about medication adherence.

RESULTS

Across the focus groups, communication difficulties between patients and providers resulting in medication non-adherence was a primary theme that emerged. Concerns about medication side effects and beliefs about medication effectiveness were identified as perceptual barriers related to intentional medication non-adherence. Practical barriers to medication adherence, including medication costs, forgetting to take medications and polypharmacy, emerged as themes related to unintentional medication non-adherence.

CONCLUSION

The study findings contribute to a growing body of research suggesting health system changes are needed to improve provider education and implement multicomponent interventions to improve medication adherence among patients with depression and/or diabetes, both chronic illnesses accounting for significant disease burden globally.

Factors Associated with Free Medicine Use in Patients with Hypertension and Diabetes: A 4-Year Longitudinal Study on Full Coverage Policy for Essential Medicines in Taizhou, China

Full coverage policies for medicines have been implemented worldwide to alleviate medicine cost burden and promote access to medicines. However, few studies have explored the factors associated with free medicine use in patients with chronic diseases. This study aimed to analyze the utilization of free medicines by patients with hypertension and diabetes after the implementation of the full coverage policy for essential medicines (FCPEM) in Taizhou, China, and to explore the factors associated with free medicine use. We conducted a descriptive analysis of characteristics of patients with and without free medicine use and performed a panel logit model to examine factors associated with free medicine use, based on an electronic health record database in Taizhou from the baseline year (12 months in priori) to three years after FCPEM implementation. After FCPEM implementation, the proportion of patients without any free medicine use decreased from 31.1% in the baseline year to 28.9% in the third year, while that of patients taking free medicines rose from 11.0% to 22.8%. Patients with lower income or education level, those with agricultural hukou, patients aged 65 and above, married patients, and patients in the Huangyan district were more likely to take free medicines. In conclusion, FCPEM contributed to improved medicine access, especially in vulnerable populations. Local policy makers should consider expanding the coverage of FCPEM to other types of medicines and cultivate the potential of social supports for patients to enhance the effectiveness of FCPEM policies.