Intentional and unintentional nonadherence to antihypertensive medication

Factors Affecting the Level of Adherence to Hypertension Medications: A Cross-Sectional Study Using the Hill-Bone Questionnaire

Background

The adherence to antihypertensive therapy plays a significant role in determining the clinical outcomes of hypertension. We aim to evaluate the level of adherence to antihypertensive medications among patients and to assess the effect of different sociodemographic factors on the level of adherence using the Hill-Bone scale for indirect assessment.

Methodology

In this cross-sectional study, we utilized a validated, face-to-face interview questionnaire to collect data on sociodemographic characteristics, participants' attitudes, and disease knowledge. The Hill-Bone questionnaire was employed to assess treatment adherence. The statistical analysis was conducted using SPSS version 28.0, where mean, standard deviation, and range were utilized for variability analysis.

Results

A total of 390 patients were included in this study. The sample comprised 56.9% of females and 56.4% of participants aged 60 years or older. Approximately 80% of participants were currently married, and 46.7% had a higher education level. The average Hill-Bone CHBPTS score was 21.23± 4.95 and indicated good adherence in 63.8% of participants. The findings showed that several factors were significantly associated with higher adherence rates, including older age (COR = 3.41, 95% CI = 1.10-10.54, p = 0.03), higher educational level (COR = 1.72, 95% CI = 1.05-2.83, p = 0.03), regular blood pressure monitoring (COR = 1.90, 95% CI = 1.10-3.30, p = 0.03), and knowledge about their medications (COR = 2.12, 95% CI = 1.14-3.94, p = 0.02).

Conclusion

The medication adherence within our population falls below the desired level. Enhanced counselling and further research are necessary to identify additional factors influencing adherence and develop effective strategies for promoting adherence to antihypertensive medications.

Adherence and utilization of short-term antibiotics: Randomized controlled study

Enhancing adherence to medication has the potential to improve clinical outcomes and decrease healthcare cost. The role of clinical pharmacist-led education on adherence to short-term antibiotic has never been investigated in Jordan. This study aimed to evaluate the impact of an educational intervention on antibiotic short-term adherence and to assess the antibiotic utilization pattern. A prospective, single blinded, randomized controlled study was conducted in a tertiary referral hospital in Jordan. Adult patients diagnosed with acute infection and prescribed a short-term antibiotic course (< 30 day) were included in the study. Recruited patients were randomly allocated into control and intervention groups. Pharmaceutical education about the correct use of antibiotic/s was provided to the intervention group. The results showed that penicillins were the most prescribed antibiotics (38.7%) followed by fluoroquinolones (23.9%) and cephalosporines (20.9%). Patients in the intervention group were more likely to be adherent to the prescribed antibiotics compared to control group (OR = 1.445, 95CI% = 1.029-2.030, p = 0.033). Employed patients, less frequent administration of antibiotic, and searching information related to the prescribed antibiotics were factors associated with better adherence to short-term antibiotic (p<0.05). The most common reasons for non-adherence were feeling better and forgetfulness to take medication. These findings highlighted that pharmacist-led educational intervention significantly enhance adherence to prescribed short-term antibiotics which is a major drive to control antibiotic resistance. Initiatives should be adopted to include patient education as a regular element in the medication dispensing process. Clinical trial registration: The trial is registered at ClinicalTrials.gov (identifier: NCT05293977).

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 therapeutic concordance approach reduces adverse drug reactions in patients with resistant hypertension

Background

Adverse drug reactions (ADRs) remain among the leading causes of therapy-resistant hypertension (TRH) and uncontrolled blood pressure (BP). We have recently reported beneficial results in BP control in patients with TRH adopting an innovative approach, defined as therapeutic concordance, in which trained physicians and pharmacists reach a concordance with patients to make them more involved in the therapeutic decision-making process.

Methods

The main scope of this study was to investigate whether the therapeutic concordance approach could lead to a reduction in ADR occurrence in TRH patients. The study was performed in a large population of hypertensive subjects of the Campania Salute Network in Italy (ClinicalTrials.gov Identifier: NCT02211365).

Results

We enrolled 4,943 patients who were firstly followed-up for 77.64 ± 34.44 months, allowing us to identify 564 subjects with TRH. Then, 282 of these patients agreed to participate in an investigation to test the impact of the therapeutic concordance approach on ADRs. At the end of this investigation, which had a follow-up of 91.91 ± 54.7 months, 213 patients (75.5%) remained uncontrolled while 69 patients (24.5%, p < 0.0001) reached an optimal BP control. Strikingly, during the first follow-up, patients had complained of a total of 194 ADRs, with an occurrence rate of 68.1% and the therapeutic concordance approach significantly reduced ADRs to 72 (25.5%).

Conclusion

Our findings indicate that the therapeutic concordance approach significantly reduces ADRs in TRH patients.

Implementation of a Novel Medication Regimen Following Cardiac Rehabilitation: an Application of the Health Action Process Approach

BACKGROUND

Medication adherence is an indispensable prerequisite for the long-term management of many chronic diseases. However, published literature suggests that non-adherence is widely prevalent. Health behavior change theories can help understand the underlying processes and allow the accumulation of knowledge in the field. The present study applied the health action process approach (HAPA) in an intensive longitudinal research design to investigate medication adherence in patients after discharge from inpatient cardiac rehabilitation.

METHOD

In total, n = 139 patients (84.9% male, M_age = 62.2 years) completed n = 2,699 daily diaries in the 22 days following discharge from inpatient cardiac rehabilitation. Patients' intentions to take medication and predictors were assessed in daily end-of-day questionnaires. Adherence to medication was measured subjectively (self-report) and objectively. Multilevel modeling was applied to disentangle the between- and within-person level.

RESULTS

Higher levels of risk awareness and self-efficacy were positively associated with intentions to take medication at both levels of analysis. Contrary to theoretical assumptions, positive outcome expectations were not associated with intention, neither between- nor within-person. In contrast to published literature, patients showed very high medication adherence (95.2% self-report, 92.2% objectively).

CONCLUSION

In line with the theoretical assumptions, the results showed that risk awareness and self-efficacy are promising modifiable factors that could be targeted to motivate patients to take medication as prescribed. Daily measurements revealed that patients took their medication as prescribed; thus, future studies should make every effort to recruit patients vulnerable to non-adherence to avoid ceiling effects.

The role of illness perceptions on medication nonadherence among patients with hypertension: A multicenter study in indonesia

Introduction: Nonadherence to antihypertensive medications is recognized as a significant cause of treatment failure. Therefore, identifying its underlying factors, particularly from the patient’s perspective, is essential for developing tailored intervention strategies. The objective of this study was to evaluate the associations between different domains of illness perception and medication nonadherence among patients with hypertension in Indonesia.

Patients and methods: A multicenter cross-sectional study was conducted among patients with hypertension aged 18 years old and older who were using antihypertensive medications in the last 3 months in the community health centers in the three cities in Indonesia. The different domains of illness perception (e.g., consequences, timeline, personal control, treatment control, identity, concerns, comprehension, and emotional response) and medication nonadherence were assessed using a validated Brief Illness Perceptions Questionnaire (BIPQ) and Medication Adherence Report Scale (MARS), respectively. A logistic regression analysis was conducted to evaluate the associations between the different domains of illness perception and medication nonadherence adjusting for confounders. The odds ratios (ORs) and 95% confidence intervals (CIs) were reported.

Results: A total of 440 participants were included, whom 41.8% reported nonadherence to antihypertensive medications. The majority of the participants were females (64.3%) and aged between 60 and 69 years old (39.5%). The treatment control (OR: 0.80, 95% confidence interval: 0.7–10.90), patient’s comprehension of hypertension (OR: 0.89, 95% CI: 0.820–0.97), and patient’s emotions (OR: 0.93, 95% CI: 0.88–0.99) were significantly associated with medication nonadherence. No significant associations were observed between the other domains of illness perception and medication nonadherence.

Conclusion: Different dimensions of illness perception were associated with non-adherence to antihypertensive medications. Educational interventions should be developed based on patients’ perception of their illness.

Magnitude and factors associated with treatment non-adherence among patients with depressive disorders at St. Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia, 2019: A cross sectional study

Background

Inadequate adherence to treatment is among the main underlying causes of depression becoming a chronic problem. In developing countries due to limited access to health care, inaccurate diagnoses, and scarcity of medications, poor adherence may become an even larger obstacle in the treatment of depression. The current study aims to assess the magnitude and factors related to treatment non-adherence among patients with depressive disorders.

Objective

To assess the magnitude and factors associated with treatment non adherence among patients with depressive disorders at St. Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia, 2019.

Methods

A hospital-based cross-sectional study was conducted among 415 respondents using systematic random sampling technique. Medication adherence was assessed by using Medication Adherence Rating Scale. Data was entered to Epi-data version 3.1 and analyzed using SPSS version 20. Binary logistic analysis was done and P-values less than 0.05 were considered statistically significant.

Results

The prevalence of treatment non-adherence among patients with depressive disorders was 26% (95%CI; 21.2, 32.5). Previous suicide attempt (AOR = 3.05, 95%CI; 1.82, 5.12), medication side effects (AOR = 2.46, 95%CI; 1.47, 4.11), moderate to high self-stigma (AOR = 2.60, 95%CI; 1.45, 4.66), and poor quality of life (AOR = 2.47, 95%CI; 1.42, 4.28) were significantly associated with treatment non-adherence among patients with depressive disorders.

Conclusion and recommendation

Treatment non-adherence is a common problem among patients being treated for depressive disorders. Previous suicide attempts, medication side effects, moderate to high self-stigma, and poor quality of life were significantly associated with treatment non-adherence. Appropriate interventions should be developed to promote measures to facilitate adherence in this group of patients, and address the associated factors when applicable.

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Assessment of Patients' Views on Drug Benefits and Risks: An Interview Study with Cardiovascular Patients

Better and balanced information strategies supporting cardiovascular patients' adherence are required. Cardiovascular drugs have outstanding morbidity and mortality benefits. This can be counteracted by patients' perceptions of risks. Drug information should help the patient but not fuel unwarranted fears. We performed a cross-sectional survey of patients admitted to a cardiology ward. We evaluated (i) the patients' general benefit-risk estimation of their pharmacotherapy; (ii) views on benefits; (iii) views on risks; and (iv) information sources. Additionally, we assessed aspects of anxiety and depression with the Patient Health Questionnaire-4 (PHQ-4). (i) 67 patients (66%) rated expected drug benefits higher than potential risks. (ii) 72% of benefits motivated the patients to take their medication as prescribed. Patients more frequently mentioned surrogate markers as benefits than clinical benefits (p < 0.001). (iii) 56% of risks mentioned were perceived as bothersome and 35% as concerning. Risks were more often perceived as bothersome and concerning by patients with higher PHQ-4 scores (p=0.016). (iv) Physicians were the most frequent information source of benefits (92% of patients) and risks (45%), and pharmacy staff for 27% and 14%, respectively. Laymen or media served as sources of information on benefits in 39%, for risks in 40%, and package leaflets in 26% and 36%. 42% of the patients would like to receive more information on benefits versus 27% on risks. Our results suggest that knowledge of benefits motivates patients to take their drugs as prescribed. There is already good information on surrogate markers for process control with active patient involvement. However, a lack of knowledge still exists in relation to clinical benefits. Regarding risks, it has been shown that patients with higher PHQ-4 scores are more likely to be bothered or concerned. Both emphases on clinical benefits and individualization depending on PHQ-4 scores may be valuable resources for patient counseling to support adherence.

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.

Effect of Electronic Prescribing Compared to Paper-Based (Handwritten) Prescribing on Primary Medication Adherence in an Outpatient Setting: A Systematic Review

BACKGROUND

Electronic prescriptions are often created and delivered electronically to the pharmacy while paper-based/handwritten prescriptions may be delivered to the pharmacy by the patients. These differences in the mode of creation and transmission of the two types of prescription could influence the rate at which outpatients fill new prescriptions of previously untried medications.

OBJECTIVES

This study aimed to evaluate literatures to determine the impact of electronic prescribing compared with paper-based/handwritten prescribing on primary medication adherence in an outpatient setting.

METHODS

The keywords and phrases "outpatients," "e-prescriptions," "paper-based prescriptions," and "primary medication adherence" were combined with their relevant synonyms and medical subject headings. A comprehensive literature search was conducted on EMBASE, CINAHL, and MEDLINE databases, and Google Scholar. The results of the search were screened and selected using predefined inclusion and exclusion criteria. The Critical Appraisal Skills Program (CASP) was used for quality appraisal of included studies. Data relevant to the objective of the review were extracted and analyzed through narrative synthesis.

RESULTS

A total of 10 original studies were included in the final review, including 1 prospective randomized study and 9 observational studies. Nine of the 10 studies were performed in the United States. Four of the studies indicated that electronic prescribing significantly increases initial medication adherence, while four of the studies suggested the opposite. The remaining two studies found no significant difference in primary medication adherence between the two methods of prescribing. The variations in the studies did not allow the homogeneity required for meta-analysis to be achieved.

CONCLUSION

The conflicting findings relating to the efficacy of primary medication adherence across both systems demonstrate the need for a standardized measure of medication adherence. This would help further determine the respective benefits of both approaches. Future research should also be conducted in different countries to give a more accurate representation of adherence.

Intentional and unintentional nonadherence to hydroxyurea among people with sickle cell disease: a qualitative study

Hydroxyurea is an efficacious treatment for sickle cell disease (SCD), but adoption is low among individuals with SCD. The objective of this study was to examine barriers to patients' adherence to hydroxyurea use regimens by using the intentional and unintentional medication nonadherence framework. We interviewed individuals with SCD age 15 to 49.9 years who were participants in the Sickle Cell Disease Implementation Consortium (SCDIC) Needs Assessment. The intentional and unintentional medication nonadherence framework explains barriers to using hydroxyurea and adds granularity to the understanding of medication adherence barriers unique to the SCD population. In total, 90 semi-structured interviews were completed across 5 of the 8 SCDIC sites. Among interviewed participants, 57.8% (n = 52) were currently taking hydroxyurea, 28.9% (n = 26) were former hydroxyurea users at the time of the interview, and 13.3% (n = 12) had never used hydroxyurea but were familiar with the medication. Using a constructivist grounded theory approach, we discovered important themes that contributed to nonadherence to hydroxyurea, which were categorized under unintentional (eg, Forgetfulness, External Influencers) and intentional (Negative Perceptions of Hydroxyurea, Aversion to Taking Any Medications) nonadherence types. Participants more frequently endorsed adherence barriers that fell into the unintentional nonadherence type (70%) vs intentional nonadherence type (30%). Results from this study will help SCD health care providers understand patient choices and decisions as being either unintentional or intentional, guide tailored clinical discussions regarding hydroxyurea therapy, and develop specific, more nuanced interventions to address nonadherence factors.

Impact of Beliefs about Medicines on the Level of Intentional Non-Adherence to the Recommendations of Elderly Patients with Hypertension

Background: Non-adherence to pharmaceutical treatment is one of the most common causes of uncontrolled hypertension. Non-adherence may be intentional or unintentional. In the case of intentional non-adherence, it is crucial to understand the reasons behind it. The literature increasingly addresses the issue of beliefs and concerns about medication, but studies on this subject performed in a Polish population of hypertensive patients are still lacking. The aim of the study was to assess the level of intentional non-adherence among patients with hypertension, and to determine the relationship between beliefs about medication and the level of intentional non-adherence to treatment in elderly patients with hypertension. Material and methods: The study included 300 patients (106 of whom were male, mean age (SD) 71.71 (8.12) years) with hypertension, treated at a hypertension clinic. The following instruments were used: the Intentional Non-Adherence Scale (INAS) for evaluating intentional non-adherence, and the Beliefs about Medicines Questionnaire (BMQ) for evaluating patients’ beliefs and opinions regarding medication. Socio-demographic and clinical data were obtained from patients’ medical records. Results: The mean (SD) INAS score in the study was 47.28 (19.12). Patients were most concerned about the harm caused by medication, and least concerned about the necessity to take medication (mean score per item 3.49 vs. 2.14). Correlation analysis demonstrated weak correlations between BMQ and INAS: higher scores for necessity were associated with more intentional non-adherence (r = 0.174, p = 0.003), while higher scores for overuse, harm, and concerns were associated with less intentional non-adherence (respectively: r = −0.253, p < 0.001 vs. r = −0.336, p < 0.001 vs. r = −0.351, p < 0.001). In multiple-factor analysis, factors increasing the level of intentional non-adherence were elderly age (β = −0.352, p = 0.009), multimorbidity (β = −2.374, p = 0.035), and a higher BMQ concerns score (β = −1.376, p < 0.001), while being single was an independent predictor decreasing intentional non-adherence (β = 5.646, p = 0.013). Conclusions: The overall level of intentional non-adherence among patients with hypertension is moderate, but approximately one third of patients with hypertension demonstrate a high level of non-adherence. Independent determinants of intentional non-adherence include concerns, elderly age, multimorbidity, and being single.

Antihypertensive Medication Adherence and Associated Factors: A Cross-Sectional Analysis of Patients Attending a National Referral Hospital in Asmara, Eritrea

BACKGROUND

Recent research suggests that poor adherence to antihypertensive medication (AHM) is a major problem in the management of hypertension. This study was therefore designed to evaluate the frequency of AHM and associated risk factors in patients attending a national referral hospital in Asmara, Eritrea.

METHODS

A total of 335 respondents (females: 222 (66.3%) participated in this cross-sectional study. Adherence to Medication was evaluated using a modified version of the Medication Adherence Report Scale (MARS). Additional data were abstracted from patients' medical records and a WHO STEPwise questionnaire.

RESULTS

The mean (±SD) age of the study participants was 59.65 (±12.20) years (females: 56.82 (±9.95) vs males: 57.17 (±9.60) years, p-value=0.001). Similarly, the median (IQR) for diastolic blood pressure (DBP) and systolic blood pressure (SBP) were 85.00 mmHg (IQR: 80.00-90.00 mmHg) and 145.00 mmHg (IQR: 130.00-160.00 mmHg), respectively. Overall, 246 (73.4%) and 244 (72.8%) participants had poor knowledge and poor adherence to AHM, respectively. In the multivariate analysis, factors associated with increased odds of poor adherence to AHM included sex (females: adjusted odds ratio (aOR): 4.95; 95% CI: 1.52-16.11, p value=0.008); employment status (Ref: employed/NGO) (self-employed: aOR: 1.95; 95% CI: 0.45-8.48, p-value=0.373) (housewife: aOR: 0.13; 95% CI: 0.04-0.413, p-value=0.001) (unemployed: aOR: 1.38; 95% CI:0.32-5.98; p-value=0.670); lack of attendance of health talk at the clinic (aOR: 2.33; 95% CI: 1.17-4.63; p-value=0.016); high cost of transportation (yes: aOR: 6.87; 95% CI: 3.25-14.52; p-value<0.001); knowledge (poor: aOR: 6.23; 95% CI: 2.36-18.05, p-value<0.001) and hypertension stage (Stage 3: aOR: 5.55; 95% CI, 1.44-21.37, p-value=0.013). Low level of knowledge regarding hypertension-related complications or associated risk factors was also noted.

CONCLUSION

The high level of poor adherence to anti-hypertension medications and low level of knowledge on hypertension should raise concern. Overall, decentralization of health care services and educational support are vital intervention pathways in this population.

Factors Associated With Nonadherence to Cardiovascular Medications: A Cross-sectional Study

BACKGROUND

Cardiovascular medications have well-established benefits in the primary and secondary prevention of cardiovascular diseases. Unfortunately, adherence to these medicines is often suboptimal. To develop interventions intended to enhance adherence to cardiovascular medications, more insight is needed into the complex character of medication nonadherence.

OBJECTIVE

The aim of the present study was to identify which factors are associated with nonadherence to cardiovascular medications in a sample of patients from Dutch community pharmacies.

METHODS

In this cross-sectional study, patients using cardiovascular medications from 23 community pharmacies were included. Patient demographics, medication and disease characteristics, knowledge, quality of life, attitude toward medicines, and satisfaction with information were assessed. Both an adherent sample (n = 146) and a sample of patients nonadherent to prescribed medications (n = 109) during the last 6 months as assessed with pharmacy refill data (proportion of days covered <80%) were selected. Associations with refill nonadherence were assessed using univariate and multivariate logistic regression analyses.

RESULTS

In total, 255 patients participated (53.3% men, 71.6 ± 10.9 years). Factors associated with cardiovascular medication nonadherence in multivariate analyses included experiencing difficulties with medication use due to forgetting, having insufficient knowledge on what to do when a dose is forgotten, and having an ambivalent attitude toward medicines (beliefs of high necessity and high concerns).

CONCLUSIONS

Intervention strategies to enhance cardiovascular medication nonadherence should be targeted mainly to the unintentional dimension of nonadherence and include information and tools to prevent forgetting. Conversely, the influence of factors that underlie intentional nonadherence, particularly patients' beliefs about medicines, should also be addressed.

Self-reported medication adherence tools in cardiovascular disease: protocol for a systematic review of measurement properties

OBJECTIVE

The aim of this review is to identify high-quality, self-reported medication adherence tools for adults with cardiovascular disease to improve health outcomes.

INTRODUCTION

Medication adherence is a complex concept affected by multiple factors and positively associated with clinical outcomes. Poor adherence to cardiovascular medications is a hindrance to the effective management of cardiovascular disease, leading to poor disease prognosis or increased risk of death. Valid and reliable measurement is crucial to identify patients with poor adherence, preferably before an adverse outcome occurs.

INCLUSION CRITERIA

This review will consider studies that include adults, aged 18 years and over, with a diagnosis of cardiovascular disease. The construct of medication adherence has three phases: initiation, implementation and discontinuation. Included tools need to measure at least one of these phases. The review will consider studies of any study design that report on the measurement properties of self-reported medication adherence tools among adults with cardiovascular disease.

METHODS

The following databases will be searched from inception to present: PubMed, MEDLINE, CINAHL, ProQuest Health and Medicine, Cochrane Library, PsycINFO, Scopus, Embase and Web of Science. Articles published in any language will be included, with no date limit. Data extraction will be performed by one reviewer and cross-checked by another reviewer. Data from the included studies will be synthesized using tables for the quality of methods, and measurement property results.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019124291.

Determinants of Non-Adherences to Long-Term Medical Therapy after Myocardial Infarction: A Cross-Sectional Study

PURPOSE

Non-adherence to medications can be classified as unintentional and intentional. The aim of this study was to establish the major determinants of each non-adherence in myocardial infarction (MI). We also evaluated the effects of non-adherences on healthy behaviors.

MATERIALS AND METHODS

We enrolled 510 patients >1 year after MI. Nonadherences classified as unintentional or intentional were measured by a self-reported questionnaire. Polynomial and multiple regression analysis were performed to evaluate the determinant of each type of nonadherences.

RESULTS

Among patients with nonadherence, 263 (70.7%) patients were unintentionally non-adherent while 109 (29.3%) patients were intentionally non-adherent. Psychological belief and attitude were important in unintentional non-adherence (Exp(β) = 0.917, p = 0.050 for anxiety; Exp(β) = 1.191, p = 0.001 for concerns). Beliefs about medications were the strongest determinant of intentional non-adherence (Exp(β) = 0.812, p < 0.001 for necessity; Exp(β) = 1.421, p < 0.001 for concerns). Anxiety was important determinant of intentional non-adherence (Exp(β) = 0.889, p = 0.015).

CONCLUSION

Psychological factors and beliefs about medication were important determinants of both types of non-adherence. Combined approaches targeting the beliefs about medications and psychological distress are needed to improve drug adherence in patients with MI.

Evaluation of Antidiabetic Injectable Technique: Is There an Association between Accuracy and Health Literacy or Duration of Diabetes?

Introduction:

Effective diabetes pharmacotherapy often involves injectable medications, which if used inappropriately represents a type of unintentional medication nonadherence that leads to poor outcomes.

Objectives:

The primary objective of this study was to assess the percent of patients who accurately prepared, administered, stored, and disposed of their injectable diabetes medication. Secondary objectives included comparing the accuracy of injectable use among those with diabetes <5 years vs. ≥ 5 years duration and those with limited vs. proficient health literacy.

Methods:

This was a prospective analysis conducted on a convenience sample of patients who received a pilot pharmacist-led, quality improvement service at an urban, ambulatory care clinic. The service components included health literacy screening, using the Rapid Assessment of Adult Literacy in Medicine – Short Form (REALM-SF) tool, evaluation of injectable technique by use of a standardized questionnaire, and provision of medication education. Duration of diabetes was determined by patient self-report. Chi-square and Fisher’s exact tests were utilized to assess accuracy of injectable technique in two group comparisons: (1) patients with limited vs. proficient health literacy and (2) patients with diabetes <5 years vs. ≥5 years.

Results:

Thirty-five patients were included in the analysis. Despite the majority (71.4%) of patients reporting prior education on injectable use, 54.3% reported at least one error in product use. Significant findings noted were that those with limited health literacy had higher rates of accurately using the skin-fold technique and appropriate angle for injection vs. those with proficient health literacy (p<0.05 for both comparisons). Likewise, more patients in the cohort of diabetes duration ≥5 years accurately rotated the injection site vs. those with a duration <5 years (p=0.001).

Conclusion:

Errors in injectable technique were common in this study and spanned across health literacy levels and duration of diabetes. Patients prescribed injectable diabetes medications should be routinely educated on proper technique for use.

A telephone reminder to enhance adherence to interventions in cardiovascular randomized trials: A protocol for a study within a trial (SWAT)

The impact of reduced adherence in randomized clinical trials is well documented in the literature. Nonadherence can negatively affect the trial sample size and estimation of the treatment effect. This protocol aims to evaluate the effects of a telephone call reminder on the adherence rates of participants to interventions in a cardiovascular randomized trial. This is a study within a trial (SWAT). The host trial is evaluating the effectiveness of a multidisciplinary 16-wk cardiovascular disease prevention program on risk factor profile among patients with carotid artery stenosis. Simultaneously, this SWAT will evaluate the effectiveness of telephone call reminders on the participants' adherence to the host trial intervention. The primary outcome is adherence to the protocol of the host trial. Secondary outcomes are level of adherence, number of dropouts, and time to drop out from the host trial.

Chronic Conditions and Behavioural Change Approaches to Medication Adherence: Rethinking Clinical Guidance and Recommendations

Patient adherence to medication is an ongoing concern for clinicians, obfuscating treatment efficacy and resulting in wastage of medicine, reduced clinical benefit, and increased mortality. Despite this, procedural guidance on how clinicians should best engage patients regarding their medicine-taking is limited in the United Kingdom. Adherence for chronic conditions is notably complex, requiring clear education, communication, and behavioural shifts to initiate and sustain daily regimens successfully. This article explores current clinician guidance on assuring patient adherence to medication within the National Health Service, comparing it to that provided for healthcare workers in the field of behavioural change. Outlining the inertia of the former and the progress of the latter, we consider what steps should be taken to address this deficit, including greater focus on patient concerns, as well as knowledge translation for healthcare professionals in future adherence research. Current United Kingdom clinical guidance for assuring patient adherence is largely outdated based on inconclusive evidence for best practice. However, efforts to encourage behavioural change in the public health setting demonstrate evidence-based success. Integrating knowledge generated around adherence behaviour and the practical application of adherence and behavioural change research, as well as funding for longer-term studies with a focus on clinical outcomes, may help to solidify the NICE guidance on adherence and further progress the field. This would require close involvement from patient groups and networks informing ethical aspects of study design and clinical implementation.

The Development of a Screening Tool to Identify and Classify Nonadherence in Inflammatory Bowel Disease

Background

Medication nonadherence is a challenge in chronic disease management. Tools that can both determine adherence levels and analyze patient-specific reasons for nonadherence are lacking.

Methods

Our tool was developed using 23 patient-reported items and its predictive performance was compared with the most widely used instrument in the literature.

Results

One hundred thirty-three IBD patients were included, 44 (33%) were nonadherent and 89 (67%) were adherent. Our screening question, with 87% sensitivity and 64% specificity, was followed by a 9-item survey for patients qualified as nonadherent.

Conclusions

Quantifying reasons for nonadherence can lead to more effective and personalized interventions for nonadherent patients.

Living environment, social support, and informal caregiving are associated with healthcare seeking behaviour and adherence to medication treatment: A cross-sectional population study

Despite the well-known associations between local environment and health, few studies have focused on environment and healthcare utilisation, for instance healthcare seeking behaviour or adherence. This study was aimed at analysing housing type, behaviour based on perceived local outdoor safety, social support, informal caregiving, demographics, socioeconomics, and long-term illness, and associations with health-seeking and adherence behaviours at a population level. This study used data from the Swedish National Public Health Survey 2004-2014, an annually repeated, large sample, cross-sectional, population-based survey study. In all, questionnaires from 100,433 individuals were returned by post, making the response rate 52.9% (100,433/190,000). Descriptive statistics and multiple logistic regressions were used to investigate associations between explanatory variables and the outcomes of refraining from seeking care and non-adherence behaviour. Living in rented apartment, lodger, a dorm or other was associated with reporting refraining from seeking care (adjusted OR 1.16, 95% CI 1.00-1.22), and non-adherence (adjusted OR 1.22; 95% CI 1.13-1.31). Refraining from going out due to a perceived unsafe neighbourhood was associated with refraining from seeking care (adjusted OR 1.59, 95% CI 1.51-1.67) and non-adherence (adjusted OR 1.26, 95% CI 1.17-1.36). Social support and status as an informal caregiver was associated with higher odds of refraining from seeking medical care and non-adherence. This study suggests that living in rental housing, refraining from going out due to neighbourhood safety concerns, lack of social support or informal caregiver status are associated with lower health-seeking behaviour and non-adherence to prescribed medication.

Antihypertensive Medication Nonpersistence and Low Adherence for Adults <65 Years Initiating Treatment in 2007-2014

Previous evidence suggests modest improvements in antihypertensive medication adherence occurred from 2007 to 2012 among US adults ≥65 years of age. Whether adherence improved over time among adults <65 years of age is unknown. We assessed trends in antihypertensive medication nonpersistence and low adherence among 379 658 commercially insured adults <65 years of age initiating treatment in 2007-2014 using MarketScan claims. Nonpersistence was defined as having no days of medication available to take during the final 90 days of the 365 days following initiation. Among beneficiaries who were persistent to treatment, low adherence was defined by having antihypertensive medication available to take for <80% of the days in the 365 days following initiation (ie, proportion of days covered <80%). In 2007 and 2014, 23.3% and 23.5% of patients were nonpersistent to treatment, respectively, and 42.3% and 40.2% had low adherence, respectively. The relative risks for nonpersistence and low adherence were lower among beneficiaries initiating treatment with an angiotensin-converting enzyme inhibitor (0.95; 95% CI, 0.94-0.97 and 0.97; 95% CI, 0.96-0.98, respectively), angiotensin receptor blocker (0.86; 95% CI, 0.85-0.88 and 0.99; 95% CI, 0.97-1.00, respectively), or multiclass regimen (0.82; 95% CI, 0.80-0.84 and 0.88; 95% CI, 0.86-0.89, respectively), prescribed 90-day versus 30-day prescriptions (0.67; 95% CI, 0.66-0.68 and 0.70; 95% CI, 0.69-0.71, respectively), or who received medications by mail versus at the pharmacy (0.93; 95% CI, 0.90-0.95 and 0.90; 95% CI, 0.88-0.92, respectively). In conclusion, several modifiable factors were associated with lower rates of both antihypertensive medication nonpersistence and low adherence among adults <65 years of age initiating treatment in 2007-2014.

Adverse effects and non-adherence to antihypertensive medications in University of Gondar Comprehensive Specialized Hospital

Background

A considerable proportion of cardiovascular events could be attributed to poor adherence to antihypertensive medications. Adverse effects can be severe enough to affect adherence to antihypertensive medications. This study aimed to measure the contribution of adverse effects on antihypertensive medications adherence.

Methods

The study was conducted from May 1 to June 30, 2017, at the ambulatory clinic of University of Gondar Comprehensive Specialized Hospital (UOGCSH) in Gondar town. A binary logistic regression was performed to determine the significance of the association between adverse effects and adherence to antihypertensive medications. An institution-based cross-sectional study was conducted by administering a questionnaire to hypertensive patients who came for follow-up at the ambulatory clinic of UOGCSH. Level of adherence to antihypertensive medications was used as outcome measure.

Results

A total of 249 patients were included in the final analysis with a mean age of 56.51 years and a female majority (53%). The following variables were identified as predictors of poor adherence: tiredness [AOR (95% CI): 3.802 (1.723-8.391), p = 0.001], muscle pain [AOR (95% CI): 5.199 (1.407-19.214), p = 0.013], poor sleep [AOR (95% CI): 4.891 (1.578-15.160), p = 0.006] and, believing that the symptoms were caused by antihypertensive medications [AOR (95% CI): 3.249 (1.248-8.456), p = 0.016].

Conclusion

Adverse effect significantly contributes to antihypertensive medication non-adherence among hypertensive patients.

Improving the assessment of medication adherence: Challenges and considerations with a focus on low-resource settings

Improving patient survival and quality of life in chronic diseases requires prolonged and often lifelong medication intake. Less than half of patients with chronic diseases globally are adherent to their prescribed medications which preclude the full benefit of treatment, worsens therapeutic outcomes, accelerates disease progression, and causes enormous economic losses. The accurate assessment of medication adherence is pivotal for both researchers and clinicians. Medication adherence can be assessed through both direct and indirect measures. Indirect measures include both subjective (self-report measures such as questionnaire and interview) and objective (pill count and secondary database analysis) measures and constitute the mainstay of assessing medication adherence. However, the lack of an inexpensive, ubiquitous, universal gold standard for assessment of medication adherence emphasizes the need to utilize a combination of measures to differentiate adherent and nonadherent patients. The global heterogeneity in health systems precludes the development of a universal guideline for evaluating medication adherence. Methods based on the secondary database analysis are mostly ineffectual in low-resource settings lacking electronic pharmacy and insurance databases and allowing refills without updated, valid prescriptions from private pharmacies. This significantly restricts the choices for assessing adherence until digitization of medical data takes root in much of the developing world. Nevertheless, there is ample scope for improving self-report measures of adherence. Effective interview techniques, especially accounting for suboptimal patient health literacy, validation of adherence questionnaires, and avoiding conceptual fallacies in reporting adherence can improve the assessment of medication adherence and promote understanding of its causal factors.

"If I'd Known …"-a Theory-Informed Systematic Analysis of Missed Opportunities in Optimising Use of Nicotine Replacement Therapy and Accessing Relevant Support: a Qualitative Study

Purpose

Nicotine replacement therapy (NRT) is often used suboptimally by smokers. Previous research has focused on cognitions and attitudes as potential reasons. This study drew on theoretical frameworks of behaviour to comprehensively explore smokers’ NRT use to identify new intervention targets.

Methods

Semi-structured face-to-face interviews were conducted with 16 adult UK-based smokers and ex-smokers who used NRT in recent quit attempts (mean (SD) age = 34.9(10.3); 82.3% women). The COM-B (capability, opportunity, motivation, behaviour) model and the theoretical domains framework informed the interviews and analyses. Data were analysed in NVivo 11.

Results

Two related behaviours were identified relevant to NRT use: use of NRT per se and engaging with information and support with NRT use. A meta-theme of “missed opportunity” identified instances when smokers did not or could not engage in these behaviours. For use of NRT per se, these included limited knowledge, poor technique of use, low motivation to optimise use, and lack of role models. For engaging with information and support, they included low awareness of optimal use techniques, selective information-seeking, low expectations, limited exposure to guidelines, deficient advice from healthcare professionals, and suboptimal product display. Prior suboptimal experience tended to negatively affect subsequent use and views. Participants were interested in accessible and comprehensive guidelines on NRT and its use.

Conclusions

There appear to be important missed opportunities for optimal use of NRT both in terms of use itself and engagement with information on optimal use. These missed opportunities arise from a range of capability, motivational, and opportunity-related factors.

Electronic supplementary material

The online version of this article (10.1007/s12529-018-9735-y) contains supplementary material, which is available to authorized users.

Use of rheumatology-specific patient navigators to understand and reduce barriers to medication adherence: Analysis of qualitative findings

Objective

Adherence to medications among patients with rheumatic diseases is often suboptimal. Patient navigators, individuals trained in care coordination, motivational interviewing and basic rheumatology and pharmacology, have not been employed to explore and address this issue. We piloted a single-site, single arm intervention to determine the feasibility and acceptability of using rheumatology-specific navigators to understand and reduce barriers to adherence to oral disease modifying anti-rheumatic drugs (DMARDs). We analyzed our qualitative findings from navigator-patient interactions as well as patient satisfaction with the intervention.

Methods

We recruited patients ≥18 years with a systemic rheumatic disease who initiated an oral DMARD within the prior 6 months. Navigators conducted baseline needs assessments and 2–4 week follow-up calls to understand and address issues related to medication adherence. We analyzed patient-navigator encounters qualitatively using content analysis to identify key themes related to barriers to adherence and navigator actions performed in response to the barriers described. We also categorized intentional and unintentional nonadherent behavior and assessed satisfaction with the navigator experience (range 0–5, 5 = most satisfied).

Results

107 rheumatology patients were followed for up to 6 months. Mean patient age was 55 years (+17) and 93% were female; 36% described one or more episode of intentional or unintentional nonadherence. The three most common themes identified as barriers to adherence were fear of adverse events (raised by 54%), concerns about medication effectiveness (43%), and challenges with medication acquisition (32%). 86% of participants described at least one adherence-related barrier. Frequent navigator actions included facilitation of patient-doctor communication (38%), medication and diagnosis education (27%), and development of individualized strategies to improve adherence (16%). Patients were satisfied with the navigator experience (mean 4.4 + 0.9).

Conclusion

Navigators uncovered and addressed a number of medication adherence-related concerns and patients were satisfied with the services provided.

Intentional and unintentional medication non-adherence in African Americans: Insights from the Jackson Heart Study

BACKGROUND

Non-adherence to medications is common and leads to suboptimal outcomes. Non-adherence can be intentional (e.g., deciding to skip dosages) or unintentional (e.g., forgetting), yet few studies have distinguished these reasons. An improved understanding of the reasons for non-adherence could inform the development of effective interventions.

METHODS AND RESULTS

We analyzed data from African Americans in the Jackson Heart Study who were prescribed medications for one or more chronic conditions. Participants were grouped by patient-reported adherence with non-adherence categorized as being intentional, unintentional or both. We used modified Poisson regression models to examine the factors associated with types of non-adherence. Of 2933 participants taking medication, 2138 (72.9%) reported non-adherence with 754 (35.3%) reporting only unintentional non-adherence, 263 (12.3%) only intentional non-adherence, and 1121 (52.4%) both. Factors independently associated with intentional non-adherence included female sex and depressive symptoms while factors associated with unintentional non-adherence included younger age and separated relationship status. Unintentional and intentional non-adherence was more common among participants taking anti-arrhythmic and anti-asthmatic medications, respectively. Higher levels of global perceived stress was associated with both types of non-adherence. The adjusted models for intentional and unintentional non-adherence had c-statistics of 0.65 and 0.66, respectively, indicating modest discrimination.

CONCLUSION

Specific patient factors and individual medication classes were associated with distinct patterns of intentional and unintentional non-adherence, yet the overall modest discrimination of the models suggests contributions from other unmeasured factors. These findings provide a construct for understanding reasons for non-adherence and provide rationale to assess whether personalized interventions can improve adherence.

Association Between Adherence to Statins, Illness Perception, Treatment Satisfaction, and Quality of Life among Lebanese patients

OBJECTIVES

The main objective of this study was to evaluate treatment adherence to statin and health-related quality of life (QOL) in Lebanese patients with dyslipidemia. Secondary objectives were to examine associations between treatment adherence, QOL, treatment satisfaction, and illness perception.

METHODS

This cross-sectional study, conducted in 20 community pharmacies from all districts of Lebanon between August 2016 and April 2017, enrolled 247 adult patients taking any statin.

RESULTS

The mean age of the participants was 52.63 ± 11.92 years (57.5% males); the mean duration of treatment with a statin was 59.72 months. A significant association was found between adherence and marital status ( P < .0001), educational level ( P = .001), cigarette smoking ( P < .0001), and alcohol drinking ( P < .0001). A negative but significant correlation was found between the adherence score and the duration of dyslipidemia ( r = -0.199). A significant but negative correlation was also found between the side effect score and age ( r = -0.137). The monthly salary, the marital status, the educational level, smoking cigarettes or waterpipes, and drinking alcohol were all associated with the Illness Perception Questionnaire scores ( P < 0.0001 for all variables). Secondary level of education (β = 13.43), smoking more than 3 waterpipes per week (β = 14.06), global satisfaction score (β = 0.32), convenience score (β = 0.29), and effectiveness score (β = 0.27) would significantly increase the adherence score. Smoking more than 15 cigarettes per day (β = -11.15) and a divorced status (β = -14.81) would however significantly decrease the adherence score. Significant associations were found between the illness perception score, the QOL domains, and the satisfaction domains ( P < .05 for all variables).

CONCLUSION

This study showed that global satisfaction with treatment, convenience, and effectiveness are important factors that increase treatment adherence. Patient adherence results in patient satisfaction and improved QOL and is an important criterion for achieving desired therapeutic outcomes.

Adherence to Antihypertensive Medication in Older Adults With Hypertension

Background/Objectives:

Effective prevention of cardiovascular events in people with hypertension requires optimal control of blood pressure. Despite advances in management, poor adherence to antihypertensive medications is often reported as the major reason attenuating treatment efficacy. Research has provided limited evidence of associations between illness perceptions, satisfaction with consultations, and medication adherence. The aim of this study is to identify factors significantly associated with medication adherence in a group of Chinese older adults with essential hypertension.

Design/Setting/Participants:

A cross-sectional correlational study was conducted. Data were collected from 195 older adults (mean [SD] age, 76 [6.6] years) recruited from 12 community centers.

Measurements:

The Illness Perception Questionnaire–Revised was used to measure illness perceptions, and the Medical Interview Satisfaction Scale was used to measure satisfaction with individual consultations. The Morisky Medication Adherence Scale was used to measure the extent of adherence to antihypertensive medications. Multivariate logistic regression analysis was performed to examine factors, including illness perceptions, consultation satisfaction, and demographic and clinical characteristics, that were significantly associated with medication adherence.

Results:

More than half of the respondents (55.9%) acknowledged some degree of medication nonadherence. Older age, living alone, and perception related to treatment control were independently associated with increased odds of medication adherence, with odds ratios ranging from 1.14 to 1.92 (P < .05).

Conclusion:

The results highlight the importance of cultivating positive beliefs that hypertension is amenable to control by treatment. Furthermore, the adherence behavior of those of younger individuals and living with family should be closely monitored.

It's all a matter of necessity and concern: A structural equation model of adherence to antihypertensive medication

OBJECTIVE

Hypertension is often treated pharmacologically, yet adherence is poor. Beliefs about antihypertensive medicine, i.e., the necessity-concern framework (NCF), are valuable for explaining adherence. Therefore, a model structure is transferred from hypercholesterolemia to hypertension, assuming a mediating role of the NCF.

METHODS

Patients with hypertension (n=273) were surveyed online about demographics, health- and treatment-related factors, control beliefs, necessity and concern beliefs about their medication, and adherence. The data were analyzed using structural equation modeling (SEM).

RESULTS

Necessity was positively (β=0.26, p=0.009) and concern was negatively (β=-0.51, p=0.020) associated with adherence. The NCF mediated the influence of background variables on adherence. Necessity was associated with comorbidity (β=-0.36, p<0.001), treatment time (β=0.19, p=0.004), emotionally supportive doctor-patient communication (β=0.12, p=0.045), side effects (β=0.16, p=0.013), personal control (β=-0.13, p=0.022), and treatment control (β=0.29, p<0.001). Concern was associated with side effects (β=0.38, p<0.001) and beliefs about medicine in general being harmful (β=0.61, p<0.001). The model fit was acceptable (RMSEA=0.61).

CONCLUSION

The transferred adherence model with the necessity-concern framework as a mediating factor was confirmed in hypertension, explaining more variance than previous approaches (23%).

PRACTICE IMPLICATIONS

A personalized, emotionally supportive doctor-patient communication could be key to addressing beliefs about medicine and therefore to increasing adherence.

Why don't patients take their medicine? Reasons and solutions in psychiatry

Over the course of a year, about three-quarters of patients prescribed psychotropic medication will discontinue, often coming to the decision themselves and without informing a health professional. Costs associated with unplanned discontinuation may be substantial if left uncorrected. Partial non-adherence (much more common than full discontinuation) can also be detrimental, although some patients rationally adjust their medication regimen without ill-effect. This article reviews the literature on non-adherence, whether intentional or not, and discusses patients' reasons for failure to concord with medical advice, and predictors of and solutions to the problem of non-adherence.

Factors associated with antihypertensive medication non-adherence: a systematic review

Non-adherence to antihypertensive medication is the most important cause of uncontrolled blood pressure and is influenced by multiple interrelating factors. Understanding the complexity of medication non-adherence and its associated factors is important to determine intervention strategies. Therefore, a systematic review was performed aimed to identify factors associated with antihypertensive medication non-adherence. Different databases were searched for observational studies reporting on factors associated with non-adherence to antihypertensive medication. Titles, abstracts and full texts were reviewed by three researchers. Subsequently, the methodological quality of each study was assessed. Factors that were extracted from the included studies were categorised as factors with consistent or inconsistent evidence to put their potential importance into perspective. Forty-four studies were included. Higher co-payment, side effects and a poor patient-provider relationship were identified as factors with consistent evidence since consistent significant relationships were found for these factors whenever studied. The relationships between non-adherence and multiple other factors were inconsistent among the reviewed studies. However, some of these factors deserve some consideration. Since multiple potentially relevant factors were identified, patient-tailored interventions focussing on identifying and addressing patients' specific barriers to adherence are needed. Further research should clarify the influence of inconsistent factors on adherence and their potential to be addressed in interventions.

Dietary Patterns, Nutrition Knowledge, Lifestyle, and Health-Related Quality of Life: Associations with Anti-Hypertension Medication Adherence in a Sample of Australian Adults

INTRODUCTION

Poor anti-hypertension medication (AHT) adherence can increase disease costs and adverse outcomes. Hypertensive individuals who have a better nutrition knowledge may lead a healthier lifestyle, have a better health-related quality of life (HRQoL) and greater confidence to change behaviour. On this basis, they may have better treatment adherence.

AIM

To explore the association between the above-mentioned variables and AHT adherence in a group of Australian adults with high blood pressure (BP) in a cross-sectional clinical and community-based study.

METHODS

Adults with high BP (n = 270) completed a questionnaire including: food frequency questionnaire (FFQ), nutrition knowledge, HRQoL, self-efficacy of diet and exercise, lifestyle and AHT adherence sections. Bivariate analysis and hierarchical logistic regression were used to explore the data.

RESULTS

Three dietary patterns were identified from the FFQ, using factor and cluster analyses (Western, Snack and Alcohol, and Balanced). We observed that following a Western dietary pattern, having lower exercise self-efficacy and shorter sleep duration were more dominant in the poor AHT adherence individuals compared to their counterparts. A positive association was observed between self-efficacy and sleep duration with AHT adherence. A Western dietary pattern was prevalent in high BP participants which slightly reduced the likelihood of good adherence.

CONCLUSION

A healthier dietary pattern, better exercise self-efficacy and adequate sleep (more than six hours a night) may increase the likelihood of AHT adherence in individuals with high BP. Interventions focusing on improving these variables are required to confirm the findings of this study.

HIV-infected patients' beliefs about their chronic co-treatments in comparison with their combined antiretroviral therapy

Objectives

Thanks to the success of combination antiretroviral therapy (cART), HIV‐infected patients can have almost a normal life expectancy. This has resulted in an aging HIV‐infected population with other chronic comorbidities such as cardiovascular diseases, osteoporosis, and depression. Our hypothesis is that patients' perceptions of and attitudes towards their cART, which is perceived as crucial to their survival, differ from their beliefs about their co‐treatments, and this may have an impact on their medication adherence.

Methods

We used the French version of the Beliefs about Medicine Questionnaire (BMQ‐f) to measure the perceptions of patients about their co‐treatments and the Beliefs about Medicine Questionnaire for Highly Active Antiretroviral Therapy (BMQ‐HAART) to measure their beliefs about their cART in a representative sample (n = 150) of patients enrolled in the Swiss HIV Cohort Study (SHCS) and followed at the Infectious Disease Service at the University Hospital in Lausanne, Switzerland. The survey was administered to all eligible patients by the order of their scheduled appointments at the end of their medical visit. The BMQ comprises two subscores: Specific‐Necessity (5 identical items in BMQ‐f and BMQ‐HAART) and Specific‐Concerns (also 5 identical items in BMQ‐f and BMQ‐HAART). The subscores were standardized by dividing the score scale by the number of questions in the scale, resulting in a range of responses between 1 (low) and 5 (high). Self‐reported medication adherence was measured using the SHCS Adherence Questionnaire (SHCS‐AQ). Adherence was defined as not missing any dose or missing one dose of the treatment in the past 4 weeks. Sociodemographic variables were retrieved by reviewing the SHCS database.

Results

A response rate of 73% (109 of 150) was achieved. A total of 105 patients were included in the analysis: their median age was 56 [interquartile range (IQR) 51, 63] years and 74 were male (70%). Eighty‐seven patients (83%) were adherent to cART and 75 (71%) were adherent to their co‐treatments (P = 0.0001). The standardized mean responses for the BMQ Specific‐Necessity subscores were 4.46 [standard deviation (SD): 0.58] and 2.86 (SD: 1.02) for cART and co‐treatments, respectively (P < 0.0001). For Specific‐Concerns, the standardized mean responses were 2.9 (SD: 1.02) for cART and 4.09 (SD: 1.02) (P < 0.0001) for co‐treatments. cART and co‐treatment concerns increased as the number of co‐treatments increased (P = 0.03 and P < 0.0001, respectively).

Conclusions

Patients had higher Necessity and lower Concerns scores for their cART in comparison with their co‐treatments. A higher percentage of patients reported being adherent to cART compared with the co‐treatments that they reported they were most likely to miss. Further research using a bigger sample size and more objective measures of adherence is needed to explore the association between adherence and patients' perceptions.

Beliefs and practices of Greek doctors in relation to patients' adherence to antihypertensive medication

Although it has been proven that decreasing the arterial blood pressure decreases cardiovascular morbidity and mortality, <25% of hypertensive patients receiving antihypertensive treatment achieve target values, which are mainly attributed to failure of the patients to comply to treatment. Ensuring patient compliance to antihypertensive treatment, to prevent the development of hypertension-associated complications, has proven to be challenging in several countries. The aim of the present study was to investigate the knowledge, perceptions and practices applied by doctors treating hypertensive patients regarding patient compliance to the prescribed treatment. We also aimed to assess the possible barriers physicians face to using reinforcement methods and currently available guidelines. A total of 202 doctors from the Serres and Drama prefectures of Greece participated in this study. The data collection comprised a quantitative method questionnaire and the data were processed using Stata 8.0 statistical software. The results demonstrated that 84.7% of the participating doctors do not use the current guidelines for compliance, whereas only 10.1% have consultations lasting >15 min when discussing the medication with their patients. In addition, the majority (84.7%) of the doctors do not practice peer mentoring and consider the most effective interventions to be providing information and discussing the medication with their patients. In conclusion, the level of patient compliance to antihypertensive medication is unsatisfactory and the main reason is considered to be the non-use of guidelines by the treating physicians. Patients may benefit from further education of health professionals in this field.

Prescription Medications: Beliefs, Experiences, Behavior, and Adherence of Sheltered Housing Residents

Background:

Data on medication utilization among residents of sheltered housing complexes (SHCs) are limited.

Objective:

To evaluate the extent of nonadherence to prescribed medications among residents of SHCs and identify factors associated with nonadherence.

Methods:

A 58 item, pre-piloted questionnaire with validated items for patient self-assessment of medication risk; adherence; disability; health beliefs, experiences, and behavior; and general items on demographics, health, and medication use was mailed to 1137 SHC residents in Aberdeen, Scotland. Predictors of nonadherence (Morisky score >0) were identified using logistic regression.

Results:

Of the 695 (61.1%) respondents, 645 (mean ± SD age, 78.2 ± 7.8 y) reported using prescribed drugs. Nonadherence was reported by 176 of 627 (28.1%) residents. The predictors of nonadherence were: disagreeing with the statement, “I ensure I have enough medicines so that I don't run out” (OR 0.48; 95% CI 0.30 to 0.77), agreeing with the statements, “I make changes in the recommended management to suit my lifestyle” (OR 1.32; 95% CI 1.09 to 1.60) and “I get confused about my medicines” (OR 1.39; 95% CI 1.10 to 1.77), younger age (OR 0.96; 95% CI 0.94 to 0.99), not getting help from someone to use the medications correctly (OR 2.20; 95% CI 1.21 to 3.99), and agreeing with the statement, “I am concerned about the side effects from my medicines” (OR 1.31; 95% CI 1.05 to 1.63).

Conclusions:

Over one-quarter of SHC residents were found to be nonadherent to prescribed drugs. Risk factors for nonadherence include younger age, confusion about drugs, lack of support for drug supply and administration, interference of treatment recommendations with lifestyle, and a perceived view of risks outweighing benefits in using recommended drug therapy.

Evaluating the Validity and Reliability of the Beliefs About Medicines Questionnaire in Low-Income, Spanish-Speaking Patients With Diabetes in the United States

Purpose The purpose of this study was to examine the reliability and validity of a Spanish version of the Beliefs about Medicines Questionnaire (BMQ) as a measure to evaluate beliefs about medications and to differentiate adherent from nonadherent patients among low-income Latino patients with diabetes in the United States. Methods Seventy-three patients were administered the BMQ and surveyed for evidence of medication nonadherence. Internal consistency of the BMQ was assessed by Cronbach's alpha along with performing a confirmatory factor analysis. Criterion validity was assessed by comparing mean scores on 3 subscales of the BMQ (General Overuse, General Harm, and Specific Necessity-Concerns difference score) between adherent patients and patients reporting nonadherence for 3 different reasons (unintentional nonadherence, cost-related nonadherence, and nonadherence due to reasons other than cost) using independent samples t tests. Results The BMQ is a reliable instrument to examine beliefs about medications in this Spanish-speaking population. Construct validity testing shows nearly identical factor loading as the original construct map. General Overuse scores were significantly more negative for patients reporting each reason for nonadherence compared with their adherent counterparts. Necessity-Concerns difference scores were significantly more negative for patients reporting nonadherence for reasons other than cost compared with those who did not report this reason for nonadherence. Conclusion The Spanish version of the BMQ is appropriate to assess beliefs about medications in Latino patients with type 2 diabetes in the United States and may help identify patients who become nonadherent to medications for reasons other than out-of-pocket costs.

Comparing medication adherence tools scores and number of controlled diseases among low literacy patients discharged from a Brazilian cardiology ward

Background Adherence to prescribed drug therapy is associated with lower rates of cardiovascular causes of death. In view of the relevance for public health, it is important to understand the relation between medication adherence tools' scores, especially in low literacy patients discharged from a cardiology ward. Objectives We aimed to assess: (a) the association between number of controlled clinical conditions and adherence tools scores, and (b) the correlation between the scores of three instruments to assess adherence. Methods We conducted a prospective study and included patients discharged from a specialized cardiovascular ward in Brazil. The results of the Beliefs about Medicines questionnaire (BMQ), the Adherence to Refills and Medication Scale (ARMS) and the MedTake test were compared. Results Of 53 included patients, most of them were elderly, and did not complete primary school. On average, there were six health conditions per patient, where two of them were not controlled. ARMS was the only tool that was associated with number of controlled health conditions (r = -0.312, p < 0.05). Moreover, ARMS (average score 15.6 ± 3.4) had significant correlation with MEDTAKE (r = 0.535, p < 0.01) and BMQ (r = 0.38, p < 0.01). BMQ and MEDTAKE were also positively correlated (r = 0.311, p < 0.05). Conclusions Clinically, higher ARMS scores (>12) suggest assumed non-adherence. It is also negatively correlated with the number of controlled clinical conditions in low literacy elderlies with cardiovascular diseases.

Trends in Antihypertensive Medication Discontinuation and Low Adherence Among Medicare Beneficiaries Initiating Treatment From 2007 to 2012

Low antihypertensive medication adherence is common. During recent years, the impact of low medication adherence on increased morbidity and healthcare costs has become more recognized, leading to interventions aimed at improving adherence. We analyzed a 5% sample of Medicare beneficiaries initiating antihypertensive medication between 2007 and 2012 to assess whether reductions occurred in discontinuation and low adherence. Discontinuation was defined as having no days of antihypertensive medication supply for the final 90 days of the 365 days after initiation. Low adherence was defined as having a proportion of days covered <80% during the 365 days after initiation among beneficiaries who did not discontinue treatment. Between 2007 and 2012, 41 135 Medicare beneficiaries in the 5% sample initiated antihypertensive medication. Discontinuation was stable during the study period (21.0% in 2007 and 21.3% in 2012; P-trend=0.451). Low adherence decreased from 37.4% in 2007 to 31.7% in 2012 (P-trend<0.001). After multivariable adjustment, the relative risk of low adherence for beneficiaries initiating treatment in 2012 versus in 2007 was 0.88 (95% confidence interval, 0.83-0.92). Low adherence was more common among racial/ethnic minorities, beneficiaries with Medicaid buy-in (an indicator of low income), and those with polypharmacy, and was less common among females, beneficiaries initiating antihypertensive medication with multiple classes or a 90-day prescription fill, with dementia, a history of stroke, and those who reached the Medicare Part D coverage gap in the previous year. In conclusion, low adherence to antihypertensive medication has decreased among Medicare beneficiaries; however, rates of discontinuation and low adherence remain high.

The feasibility of determining the effectiveness and cost-effectiveness of medication organisation devices compared with usual care for older people in a community setting: systematic review, stakeholder focus groups and feasibility randomised controlled trial

BACKGROUND

Medication organisation devices (MODs) provide compartments for a patient's medication to be organised into the days of the week and the recommended times the medication should be taken.

AIM

To define the optimal trial design for testing the clinical effectiveness and cost-effectiveness of MODs.

DESIGN

The feasibility study comprised a systematic review and focus groups to inform a randomised controlled trial (RCT) design. The resulting features were tested on a small scale, using a 2 × 2 factorial design to compare MODs with usual packaging and to compare weekly with monthly supply. The study design was then evaluated.

SETTING

Potential participants were identified by medical practices.

PARTICIPANTS

Aged over 75 years, prescribed at least three solid oral dosage form medications, unintentionally non-adherent and self-medicating. Participants were excluded if deemed by their health-care team to be unsuitable.

INTERVENTIONS

One of three MODs widely used in routine clinical practice supplied either weekly or monthly.

OBJECTIVES

To identify the most effective method of participant recruitment, to estimate the prevalence of intentional and unintentional non-adherence in an older population, to provide a point estimate of the effect size of MODs relative to usual care and to determine the feasibility and acceptability of trial participation.

METHODS

The systematic review included MOD studies of any design reporting medication adherence, health and social outcomes, resource utilisation or dispensing or administration errors. Focus groups with patients, carers and health-care professionals supplemented the systematic review to inform the RCT design. The resulting design was implemented and then evaluated through questionnaires and group discussions with participants and health-care professionals involved in trial delivery.

RESULTS

Studies on MODs are largely of poor quality. The relationship between adherence and health outcomes is unclear. Of the limited studies reporting health outcomes, some reported a positive relationship while some reported increased hospitalisations associated with MODs. The pre-trial focus groups endorsed the planned study design, but suggested a minimum recruitment age of 50-60 years. A total of 35.4% of patients completing the baseline questionnaire were excluded because they already used a MOD. Active recruitment yielded a higher consent rate, but passive recruitment was more cost-effective. The prevalence of intentional non-adherence was 24.7% [n = 71, 95% confidence interval (CI) 19.7% to 29.6%] of participants. Of the remaining 76 participants, 46.1% (95% CI 34.8% to 57.3%) were unintentionally non-adherent. There was no indication of a difference in adherence between the study arms. Participants reported a high level of satisfaction with the design. Five adverse/serious adverse events were identified in the MOD study arms and none was identified in the control arms. There was no discernible difference in health economic outcomes between the four study arms; the mean intervention cost was £20 per month greater for MOD monthly relative to usual supply monthly.

CONCLUSIONS

MOD provision to unintentionally non-adherent older people may cause medication-related adverse events. The primary outcome for a definitive MOD trial should be health outcomes. Such a trial should recruit patients by postal invitation and recruit younger patients.

FUTURE WORK

A study examining the association between MOD initiation and adverse effects is necessary and a strategy to safely introduce MODs should be explored. A definitive study testing the clinical effectiveness and cost-effectiveness of MODs is also required.

STUDY REGISTRATION

Current Controlled Trials ISRCTN 30626972 and UKCRN 12739.

FUNDING

This project was funded by National Institute for Health Research (NIHR) Health Technology Assessment Programme and will be published in full in Health Technology Assessment; Vol. 20, No. 50. See the NIHR Journals Library website for further project information.

The Effectiveness of Mobile Phone Text Messaging in Improving Medication Adherence for Patients with Chronic Diseases: A Systematic Review

Context

Medication non-adherence is a commonly observed problem in the self-administration of treatment, regardless of the disease type. Text messaging reminders, as electronic reminders, provide an opportunity to improve medication adherence. In this study, we aimed to provide evidence addressing the question of whether text message reminders were effective in improving patients’ adherence to medication.

Evidence Acquisition

We carried out a systematic literature search, using the five electronic bibliographic databases: PubMed, Embase, PsycINFO, CINAHL, and the Cochrane central register of controlled trials. Studies were included on the basis of whether they examined the benefits and effects of short-message service (SMS) interventions on medication adherence.

Results

The results of this systematic review indicated that text messaging interventions have improved patients’ medication adherence rate (85%, 29.34). Included in the review, those who had problems with adherence, or those whom text messaging was most helpful had HIV, asthma, diabetes, schizophrenia and heart disease (73.5%). The period of intervention varied from 1 week to 14 months. The most common study design was randomized controlled trials (RCTs) (66%) carried out in the developed countries.

Conclusions

This study demonstrated the potential of mobile phone text messaging for medication non-adherence problem solving.

Relationship Between Health Literacy and Unintentional and Intentional Medication Nonadherence in Medically Underserved Patients With Type 2 Diabetes

PURPOSE

The purpose of this study was to investigate the relationship between health literacy and overall medication nonadherence, unintentional nonadherence, and intentional nonadherence. Limited health literacy may be associated with worse diabetes outcomes, but the literature shows mixed results, and mechanisms remain unclear. Medication adherence is associated with diabetes outcomes and may be a mediating factor. Distinguishing between unintentional and intentional nonadherence may elucidate the relationship between health literacy and nonadherence in patients with type 2 diabetes.

METHODS

Cross-sectional study of 208 patients with type 2 diabetes recruited from a primary care clinic in St. Louis, Missouri. Information was obtained from written questionnaire and patient medical records. Bivariate and multivariable regression were used to examine predictors of medication nonadherence.

RESULTS

The majority of patients in the study were low income, publicly insured, and African American, with limited health literacy and a high school/GED education or less. In multivariable models, limited health literacy was significantly associated with increased unintentional nonadherence but not intentional nonadherence.

CONCLUSIONS

Results suggest differences in factors affecting intentional and unintentional nonadherence. The findings also suggest interventions are needed to decrease unintentional nonadherence among patients with type 2 diabetes and limited health literacy. Efforts to address unintentional medication nonadherence among patients with type 2 diabetes with limited health literacy may improve patient health.

Factors related to intentional and unintentional medication nonadherence in elderly patients with hypertension in rural community

PURPOSE

We assessed medication nonadherence, categorized as intentional or unintentional, and related factors in elderly patients with hypertension, correlating the data with measurement of blood pressure as the final target of medication adherence and other possible influencing factors, such as lifestyle.

PATIENTS AND METHODS

Subjects were aged ≥65 years, resided in a rural area, and were taking antihypertensive drugs. The survey was conducted in July 2014. Participants were divided into the following three groups: "Adherence", "Unintentional nonadherence", and "Intentional nonadherence". Individual cognitive components, such as necessity and concern as well as self-efficacy and other related factors, were compared according to adherence groups. The interrelationships between those factors and nonadherence were tested using structural equation modeling analysis.

RESULTS

Of the 401 subjects, 182 (45.6%) were in the adherence group, 107 (26.7%) in the unintentional nonadherence group, and 112 (27.9%) in the intentional nonadherence group. Necessity and self-efficacy were found to have a significant direct influence on unintentional nonadherence behaviors (necessity β=-0.171, P=0.019; self-efficacy β=-0.433, P<0.001); concern was not statistically significant (β=-0.009, P=0.909). Necessity was found to have significant direct and indirect impact on intentional nonadherence (direct β=-0.275, P=0.002; indirect β=-0.113, P=0.036). Self-efficacy had no significant direct effect on intentional nonadherence though it had the only significant indirect effect on intentional nonadherence (direct β=-0.055, P=0.515; indirect β=-0.286, P<0.001). Concern had no significant influence on intentional or on unintentional nonadherence (direct β=0.132 0.132, P=0.151; indirect β=-0.006, P=0.909).

CONCLUSION

Unintentional nonadherence should be regularly monitored and managed because of its potential prognostic significance. Interventions addressing cognitive factors, such as beliefs about medicine or self-efficacy, are relatively difficult to implement, but are essential to improve medication adherence.

Patient-Reported Factors Associated With Poor Phosphorus Control in a Maintenance Hemodialysis Population

OBJECTIVE

The purpose of this study was to determine the influence of patient-reported medication adherence and phosphorus-related knowledge on phosphorus control and pharmacy-reported adherence to phosphorus binding medication among patients on maintenance hemodialysis.

DESIGN

Retrospective, cross-sectional cohort study.

SUBJECTS

Seventy-nine hemodialysis patients (mean age 64.2 years, SD = 14 years; 46.8% female) in a stand-alone hemodialysis unit within an integrated learning healthcare system. Ten percent (10%) of subjects were Caucasian, 42% Latino, 19% African American, and 29% Asian. Forty-eight percent had diabetes; 72% had BMI ≥ 30. Inclusion criteria included the provision of survey data and having medication refill data available in the pharmacy system. 77.2% had mean phosphorus levels ≤ 5.5 mg/dL; 22.8% had mean phosphorus levels > 5.5 mg/dL.

INTERVENTION

Subjects were administered the 8-item Morisky Medication Adherence Scale (MMAS-8) and also reported on their phosphorus-related knowledge.

MAIN OUTCOME MEASURE

Phosphorus levels within an adequate range.

RESULTS

The mean serum phosphorus level was 4.96 mg/dL (SD = 1.21). In the well-controlled group, mean phosphorus was 4.44 mg/dL (SD = 0.76). In the poorly controlled group, mean phosphorus was 6.69 mg/dL (SD = 0.74). A total of 61% of patients reported at least some unintentional medication nonadherence, and 48% reported intentional medication nonadherence. Phosphorus-specific knowledge was low, with just under half of patients reporting that they could not name two high-phosphorus foods or identify a phosphorus-related health risk. Phosphorus binder-related nonadherence was substantially higher in the uncontrolled than the controlled group. Adjusting for age, individuals with poorer self-reported binder adherence were less likely to have controlled phosphorus levels (odds ratio = 0.71, P = .06).

CONCLUSION

Phosphorus-related non-adherence, but not low phosphorus-specific knowledge, was associated with poorer phosphorus control. Such findings provide important information for the development of evidence-based strategies for improving phosphorus control among patients on dialysis.

Electronic messaging support service programs improve adherence to lipid-lowering therapy among outpatients with coronary artery disease: an exploratory randomised control study

AIMS AND OBJECTIVES

To compare drug adherence to lipid-lowering therapy among outpatients with coronary artery disease who received information via short message service, via short message service and Micro Letter, or via phone only.

BACKGROUND

Messaging applications and short message service are commonly used internationally. However, little is known about how coronary artery disease outpatients in China may benefit from receiving health education through these technologies.

DESIGN

Random sampling method.

METHODS

Data were collected from March-December 2013. Subjects from Chengdu City, China, were randomised to three groups: short message service, short message service + Micro Letter, and phone (control). Appointment reminders and health information were delivered to patients in accordance with designations. After six months, adherence to statin prescriptions was compared among the groups by using the Morisky Medication Adherence Scale. Logistic regression analysis was applied to determine those independent variables that were related to adherence.

RESULTS

The short message service and short message service + Micro Letter groups had better cumulative adherence (lower Morisky Medication Adherence Scale scores) after six months than phone group, and the short message service + Micro Letter group had better cumulative adherence (lower Morisky Medication Adherence Scale scores) than the short message service group. Female sex, older age and marriage show positive associations with adherence.

CONCLUSIONS

Short message service and messaging applications, such as Micro Letter, are effective means of providing discharged patients with reminders and coronary artery disease-related health information. Implementation of a short message service + Micro Letter program can improve outpatient adherence to medication.

RELEVANCE TO CLINICAL PRACTICE

This research offers useful information to help medical staff design effective interventions to improve medication compliance among coronary artery disease patients.

Cultural Beliefs Underlying Medication Adherence in People of Chinese Descent in the United States

This article examines the meanings, practices, and cultural beliefs underlying medication adherence in people of Chinese descent living in the United States. The narratives were analyzed using interpretive phenomenology, resulting in the following themes that influenced the communication and behaviors around medication adherence of the participants: (a) cultural concepts of yin yang balance and "qi," (b) understandings of Western and Chinese medicine's efficacy profiles, (c) importance of family and social support, and (d) level of acculturation. This article discusses the influence of these themes on medication adherence and proposes that health communication campaigns, interventions, and doctor-patient communication about increasing medication adherence with people of Chinese descent should engage these understandings.

Validation of the Adherence Barriers Questionnaire - an instrument for identifying potential risk factors associated with medication-related non-adherence

Background

Medication non-adherence is a major challenge in the real-life treatment of chronically ill patients. To meet this challenge, adherence interventions with a tailored approach towards patient-specific adherence barriers that are identified with a reliable and practicable questionnaire are needed. The aim of this investigation was to develop and validate such a questionnaire, the “Adherence Barriers Questionnaire (ABQ)”.

Methods

The German ABQ was developed and tested in 432 patients with atrial fibrillation in a multicentre observational cohort study. Evaluation of the questionnaire included an assessment of internal consistency as well as factor analysis. Criterion-related external validity was assessed by comparing the ABQ score with (1) the degree of self-reported adherence and (2) the time in therapeutic range which describes the anticoagulation quality achieved by patients treated with oral anticoagulation.

Results

The final 14-item ABQ scale demonstrated high internal consistency (Cronbach’s alpha = 0.820). Factor analysis identified a three-factor solution, representing intentional adherence barriers with 5 items (31.9% of the variance), medication-/health care system-related adherence barriers with 5 items (13.3% of the variance) and unintentional adherence barriers with 4 items (7.7% of the variance).

The ABQ correlated significantly with self-reported non-adherence (Spearman’s rho = 0.438, p < 0.001) as well as time in therapeutic range (Spearman’s rho = − 0.161, p < 0.010). Patients with above-average ABQ scores (increased number and/or strength of existing adherence barriers) were significantly (p < 0.005, Pearson Chi-Square) more likely to have a poor anticoagulation quality (TTR < 60%) than patients with a lower ABQ score (44.6% versus 27.3%).

Conclusions

The ABQ is a practicable, reliable and valid instrument for identifying patient-specific barriers to medication-related adherence. Future research is required to examine the ability of the ABQ to identify patient perception/behaviour changes over time which may be important for the measurement of success of adherence interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0809-0) contains supplementary material, which is available to authorized users.