Mixed-methods approach to determine adherence,knowledge and behavioral determinants associated with medication wastage

BackgroundWhile literature quantifying medication wastage and assessing public's knowledge and practices about medication disposal is substantial, less attention is given to the public's knowledge and behavior pertaining to medication wastage prevention. This study aimed to determine the public's knowledge of medication wastage, any association between knowledge and adherence, and behavioral determinants potentially leading to wastage.MethodsA mixed-method explanatory sequential approach was adopted with a quantitative survey followed by qualitative semi-structured interviews. Maltese residents ≥18 years attending social/educational events were recruited in this mixed-methods study. Participants completed a structured questionnaire comprising: 1) demographics; 2) medication adherence using ‘Tool for Adherence Behaviour Screening’ dichotomized into ‘good adherence’/‘suboptimal adherence’; 3) eight knowledge statements each carrying one point (total, 0 = lowest; 8 = highest); 4) and whether they had unused medication at home. Chi-square analysis determined associations between demographics and adherence, and having unused medication. Multiple regression was performed to predict knowledge based on demographics, adherence, having regular medication and having unused medication, p ≤0.05. Questionnaire respondents expressing interest in participating in semi-structured face-to-face interviews, based on the Theoretical Domains Framework (TDF), were recruited consecutively until data saturation. Interviews were audio-recorded, transcribed and analyzed using the Framework Approach.ResultsOf the 524 individuals attending 14 events, 80.5% completed the questionnaire (mean age±standard deviation (SD): 65 ± 13 years). Thirty-one percent (n = 130/422) of respondents reported having unused medication and 18.8% (58/309 taking chronic medication) classified as ‘optimal’ adherence. Mean ± SD knowledge score was 4.7 ± 1.5. Knowledge and adherence were not significantly related. Most prevalent TDF domains influencing wastage emerging from 15 interviews were knowledge, beliefs about consequences and behavioral regulation.ConclusionPublic's knowledge about medication wastage and adherence were inadequate, necessitating implementation of tailored educational interventions based on behavioral determinants recognized within this study. Identified inadequate behavior around disposal mandates inclusion of environmental/social planning issues when developing policies.     

Ascertaining Problems with Medication Histories

Background:

Accurate and complete medication histories are not always obtained in clinical practice.

Objective:

This qualitative research study was undertaken to explore the barriers to and facilitators of obtaining accurate medication histories.

Methods:

Individual interviews, based on a structured interview guide, were conducted with 25 patients from both inpatient and ambulatory care clinic settings. Focus groups, based on a semistructured interview guide, were conducted with pharmacists, medical residents, and nurses. Transcribed data were analyzed by forming coded units and assessing these units for emerging themes.

Results:

Major themes that emerged from the patient interviews included patient ownership of health and medication knowledge (with knowledge of medications and their side effects and how to take medications being seen as important), patient-specific strategies to improve medication histories (e.g., use of regularly updated medication lists), and suggestions for system-level facilitators to improve medication histories (e.g., centralized databases of medication histories, increased patient education regarding the use and purpose of medications). Major themes also emerged from focus groups with health care professionals, including shared responsibility for medication history-taking among all 3 health care professions, perceptions about the barriers to medication history-taking (including patients not knowing their medications and not bringing their medication lists), and suggestions to improve medication histories (e.g., educating patients to bring medication vials to hospital admissions and appointments, using a centralized computer database for medication histories).

Conclusions:

Key recommendations resulting from this study include using standardized documentation techniques for medication histories, recording of medication history information in centralized electronic databases, educating patients to bring medications to every health care visit, and establishing criteria for pharmacist referral for cases involving complex medication histories.     

A survey on the knowledge, beliefs and behaviour of a general adult population in Malaysia with respect to the adverse effects of medicines

Objective The aim of the study was to explore, in the Malaysian general population: knowledge and beliefs of the characteristics in general of medication‐related side effects and side effects associated with different types of medicines; behaviour related to the safe use of drugs before and after taking a medication; and behaviour in the event of a medication‐related side effect. Methods A 24‐item self‐administered questionnaire was developed and used to survey the general public living or working in suburban Kuala Lumpur, Malaysia. Eight hundred questionnaires were distributed, face to face, by researchers using quota sampling. Respondents’ knowledge, belief and behaviour were analysed and correlated with demographics, medical history and experience of side effects. Key findings Six hundred and ten respondents completed the questionnaire giving a response rate of 76.3%. The mean knowledge score for the respondents was 18.4 ± 3.6 out of the maximum possible score of 26. Educational level and experience of side effect had an influence on the knowledge score obtained. Respondents had misconceptions regarding the safety of complementary and alternative medicines (CAMs) and over‐the‐counter medications. Medication history and previous experience with side effects had a significant influence on the higher behaviour score obtained. Conclusion The survey has shown moderate results with regard to the knowledge of public regarding safety of medications, and there was evidence of under‐estimating the risk of medications, especially CAMs. The misconceptions among the public, and inappropriate behaviour on drug safety‐related aspects, is a concern which needs to be addressed in the interventions designed.     

Transitions of care: Medication-related barriers identified by low socioeconomic patients of a federally qualified health center following hospital discharge

This article describes a qualitative research study using a semi-structured interview process to describe barriers surrounding medication access, use, and adherence for recently discharged patients of a federally qualified health center. Common themes which emerged were: 1) Team assumptions regarding patient plans to access or appropriately use discharge medications negatively impact adherence; 2) Unmet expectation for care coordination between primary care physician (PCP) and hospital; 3) Disconnect between patients and health care workers leads to disengagement; and 4) Lack of personal contact hinders access to services.     

Effect of information leaflets and counselling on antidepressant adherence: open randomised controlled trial in a psychiatric hospital in Kuwait

Objective To assess the acceptability and effectiveness of two educational initiatives on patterns of antidepressant medication use in depressed Kuwaiti patients. Setting Patients were interviewed on three occasions at the Psychological Medicine Hospital, Kuwait. Method Two‐hundred and seventy‐eight patients attending a hospital outpatient clinic in Kuwait and receiving a single antidepressant for mild or moderate depression were randomised into a control and two treatment groups. Medication was dispensed from the pharmacy as normal. However, members of the treatment groups additionally received a patient information leaflet (PIL) written in Arabic with or without counselling from a clinical pharmacist. Medication adherence was monitored 2 months and 5 months later by self‐report and tablet counting. Patient knowledge of medication and the acceptability of the educational interventions were assessed after 2 months using questionnaires. Key findings Patients in each of the treatment groups had an improved knowledge of the rationale behind their therapy. Clinic attendance was more likely when patients had received a PIL (odds ratio (OR) 2.1, 95% confidence interval (CI) 1.3‐3.2) or a PIL plus counselling (OR 3.2, CI 2.1–4.9). Good medication adherence at 2 and 5 months was more common in patients who were given a PIL (OR 3.0, CI 1.7‐5.3) or a PIL plus counselling (OR 5.5, CI 3.2–9.6). Certain pre‐existing patient attitudes to therapy and the occurrence of side‐effects were not determinants of adherence. Conclusions Patient responses to each of these educational interventions were very positive. After 5 months, patients receiving a PIL were more likely to be adhering to their medication regimen, particularly when they had also received counselling from a clinical pharmacist.     

Implementation of a community liaison pharmacy service: a randomised controlled trial

Objective The aim of this study was to provide a pharmacy service to improve continuity of patient care across the primary‐secondary care interface. Setting The study involved patients discharged from two acute‐care tertiary teaching hospitals in Melbourne, Australia, returning to independent living. Methods Consecutive patients admitted to both hospitals who met the study criteria and provided consent were recruited. Recruited patients were randomised to receive either standard care (discharge counselling, provision of compliance aids and communication with primary healthcare providers when necessary) or the intervention (standard care and a home visit from a community liaison pharmacist (CLP) within 5 days of discharge). Participant medication was reviewed during the visit according to set protocols and compliance and medication understanding was measured. All participants were telephoned 8–12weeks after discharge to assess the impact of the intervention on adherence and medication knowledge. Key findings The CLP visited 142 patients with a mean time of 4.2 days following hospital discharge (range = 1–14 days). Consultations lasted 15–105 min (mean, 49 min; SD, ± 21 min). The CLPs retrospectively coded 766 activities and interventions that occurred during home visits, subsequently categorised into three groups: counselling and education, therapeutic interventions and other interventions. No statistical difference was detected in the number of medications patients reported taking at follow‐up: the mean value was 7.72 (SD, ± 3.27) for intervention patients and 7.55 (SD, ± 3.27) for standard‐care patients (P = 0.662). At follow‐up self‐perceived medication understanding was found to have improved in intervention patients (P < 0.001) and significant improvements from baseline in medication adherence were found in both standard‐care (P < 0.022) and intervention (P < 0.005) groups; however, adherence had improved more in intervention patients. Conclusion The community liaison pharmacy service provided critical and useful interventions and support to patients, minimising the risk of medication misadventure when patients were discharged from hospital to home.     

Haemodialysis patients' beliefs about treatment: implications for adherence to medication and fluid‐diet restrictions

Objectives — To assess haemodialysis patients' beliefs about treatment and to investigate which beliefs correlate with adherence to medication and fluid‐diet restrictions. Methods — Forty‐seven haemodialysis patients receiving intermittent hospital haemodialysis completed questionnaires assessing their beliefs about medication and fluid‐diet restrictions. Key findings — Adherence rates varied between and within patients, and were related to specific treatment beliefs in a logically consistent way. Reported intentional non‐adherence to medication correlated with concerns about the potential adverse effects of renal medication. Low adherence to fluid‐diet restrictions (assessed by inter‐dialysis weight gain) was associated with the personal belief that the restrictions were too strict. Most patients (90 per cent) agreed that medicines prescribed for their renal condition were necessary for maintaining health. However, 32 per cent harboured concerns about their medication, arising from beliefs about the potential for dependence, long‐term effects, or disruption of life. Concerns about renal medication correlated with more general beliefs that medicines as a whole are harmful, addictive poisons which are overused by doctors. Although specific treatment beliefs (medication or fluid‐diet restrictions) were related to specific adherence behaviours, these two areas of beliefs and behaviours were unrelated. Conclusions — Patients' perceptions of treatment merit further study. Eliciting and addressing patients' perceptions of treatment may be a target for pharmaceutical care and a foundation for partnership in medicine‐taking.     

Identification of psychosocial factors which influence patient adherence with antihypertensive medication

□ It is estimated that only 50 per cent of hypertensive patients adhere to medication regimens □ In this study evaluation of self‐efficacy and the theory of planned behaviour was used to identify psychosocial factors which impact on patient adherence to antihypertensives □ High self‐efficacy, intentions to comply with the medication regimen, possessing a positive attitude towards taking medication, perceiving pressure from significant others to take medication as prescribed, and perceiving control over taking medication were determinants of good adherence □ The successful identification of factors which influence adherence will allow health‐care providers to implement interventions, aimed at enhancing adherence with antihypertensive medication.     

A holistic conceptual framework model to describe medication adherence in and guide interventions in diabetes mellitus

Background

Nonadherence to medications in patients with diabetes, which results in poor treatment outcomes and increased healthcare costs, is commonly reported globally. Factors associated with medication adherence have also been widely studied. However, a clear and comprehensive, disease-specific conceptual framework model that captures all possible factors has not been established.

Drug‐related problems in the elders of the British Virgin Islands

Objective — To explore the extent of drug‐related problems in elderly patients in the Caribbean. Methods — Comprehensive medication reviews were carried out on a 1 in 20 sample of the elderly population of the British Virgin Islands, a UK dependent territory located in the Caribbean. Fifty non‐institutionalised patients, 65 years or older and taking at least one prescribed medicine, were interviewed for the study. Key findings — On average, 4.5 prescribed medications, 4.7 over‐the‐counter preparations and 3.3 herbal remedies/natural products were used by the sample. A mean of 5.9 potential drug‐related problems per patient were identified and a mean of 3.7 complications relating to the sub‐optimal use of medicines per patient were observed. Conclusion — This study has highlighted the need for a multidisciplinary review of the prescribing, dispensing and monitoring of elderly patients receiving prescribed medications. The pharmacist has a role to play in helping prescribers achieve this review, and in educating patients in ways in which they can get the best out of their medicines.     

Development and content validation of measures assessing adherence barriers and behaviors for use in clinical care

BackgroundProviders are often unaware of poor adherence to prescribed medications for their patients with chronic diseases.ObjectiveTo develop brief, computer-administered patient-reported measures in English and Spanish assessing adherence behaviors and barriers.Design, Participants, and Main Measures: Item pools were constructed from existing measures of medication adherence behaviors and barriers, which informed development of a patient concept elicitation interview guide to identify medication adherence behavior and barrier-related concepts. Two hundred six patients either living with HIV (PLWH) or without were interviewed. Interviews were coded, concepts matched to item pool content, and new items were developed for novel concepts. A provider/investigator team highlighted clinically relevant items. Cognitive interviews were conducted with patients on final candidate items (n = 37). The instruments were administered to 2081 PLWH.Key resultsBehavioral themes from concept elicitation interviews included routines incorporating time of day, placement, visual cues, and intentionality to miss or skip doses. Barrier themes included health-related (e.g. depressed mood, feeling ill), attitudes/beliefs (e.g., need for medication), access (e.g., cost/insurance problems), and circumstantial barriers (e.g., lack of privacy, disruption of daily routine). The final instruments included 6 behavior items, and 1 barrier item with up to 23 response options. PLWH endorsed a mean (SD) of 3.5 (1.1) behaviors. The 201 PLWH who missed ≥2 doses in the previous week endorsed a mean (SD) of 3.1 (2.5) barriers. The intraclass correlation coefficient (ICC) for the numbers of behaviors endorsed in 61 PLWH after 4–16 days was 0.54 and for the number of barriers for the 20 PLWH with ≥2 missed doses the ICC was 0.89, representing fair and excellent test-retest reliability.ConclusionMeasures of medication adherence behaviors and barriers were developed for use with patients living with chronic diseases focusing on clinical relevance, brevity, and content validity for use in clinical care.     

Psychotropic medicine beliefs,side effects and adherence in schizophrenia: a patient–caregiver dyad perspective

Background Medication adherence is essential in the management of schizophrenia. Yet poor treatment uptake has negative consequences on patients and their primary caregivers. Objective To examine the association among beliefs about psychotropic medications, side effects and adherence from a patient-caregiver dyad perspective. Setting This study was conducted in a public psychiatric hospital setting in Accra, Ghana. Methods A cross-sectional study was conducted among 121 patient-caregiver dyads using an interviewer-administered data collection approach.Main outcome measure Beliefs about medicines, side-effects and medication adherence. Results The patient and caregiver-reported level of medication adherence was 28.1?%. Using the Kappa index, the level of agreement between the responses of patients and their caregivers ranged from slight to moderate. Both patients and caregivers rated necessity higher than concern (patients: 1.67?±?0.84, caregiver: 1.79?±?0.96). Significant positive relations between specific-necessity, necessity–concerns differential and medication adherence were recorded while specific–concern, general harm and side-effects correlated negatively with medication adherence from the dyad. The odds of adhering to medications increased by 58 and 64?% for each unit increase in specific-necessity and general overuse scores respectively. However, a unit increase in specific–concern score and high side-effects scores were associated with lower odds of adherence. Conclusions This study highlights the need for patient-caregiver collaborations in decision-making relating to medication adherence in schizophrenia. Thus, in clinical practice, there is the need to recognize that caregivers are essential partners, and patient-caregiver views about psychotropic medications are critical in enhancing adherence for positive mental health outcomes.

     

The development and evaluation of an extended adherence support programme by community pharmacists for elderly patients at home

Objective —To devise, implement and evaluate a medication adherence support service by community pharmacists for elderly patients living at home and at risk of non‐adherence. Method — Six community pharmacists identified patients who were 65 years of age and older, prescribed four or more regular medicines and living alone. A random sample of patients was visited at home and assessed for adherence‐related problems using a structured interview. The pharmacist then drew up an action plan in conjunction with the patient and general practitioner (GP), and returned for a second home visit, where the revised regime was delivered and explained. A self‐reported adherence questionnaire was also administered. After two months an independent researcher visited the patients at home to assess progress. Setting — Six community pharmacies in the city of Leeds, UK, and patients' homes. Key findings — A total of 143 patients were recruited and 441 medicine‐related problems were identified. Of these, 241 (55 per cent) required the provision of information and advice, 106 (24 per cent) required consultation with the GP and 86 (20 per cent) required changes in the presentation of the medicines. The median number of regular prescribed medicines fell from six to five (P<0.001). Overall, there was a reduction in the number of patients with one or more problems from 94 per cent to 58 per cent (P<0.001). The proportion of patients who reported non‐adherence fell from 38 per cent to 14 per cent (P<0.001). Conclusion — This study shows that community pharmacists can target patients at risk of medication non‐adherence and, using a structured approach, identify problems and implement solutions. The pharmacy patient medication record is an underutilised tool for identifying patients with adherence problems. The software needs enhancing to enable pharmacists to maximise their use of these records in adherence support. An adherence support programme needs to take more account of intentional non‐adherence and should be closely linked with the rest of the primary health care team.     

The journey to concordance for patients with hypertension: a qualitative study in primary care

Objective We aimed to explore, using qualitative methods, the perspectives of patients with hypertension on issues relating to concordance in prescribing. Method This study took place in NHS general practices in Northern Ireland. A purposeful sample of patients who had been prescribed anti-hypertensive medication for at least one year were invited to participate in focus groups or semi-structured interviews; data were analysed using constant comparison. Main outcome measures The perspectives of patients with hypertension on issues relating to concordance in prescribing. Results Twenty-five individuals participated in five focus groups; two participated in semi-structured interviews. Participants felt they could make valuable contributions to consultations regarding their management. They were prepared to negotiate with GPs regarding their medication, but most deferred to their doctor’s advice, perceiving doctors’ attitudes and time constraints as barriers to their greater involvement in concordant decision-making. They had concerns about taking anti-hypertensive drugs, were aware of lifestyle influences on hypertension and reported using personal strategies to facilitate adherence and reduce the need to take medication. Conclusions Participants indicated a willingness to be␣involved in concordance in prescribing anti- hypertensive medication but needed health professionals to address their concerns and confusion about the nature of hypertension. These findings suggest that there is a need for doctors and other healthcare professionals with responsibility for prescribing to develop skills specifically to explore the beliefs and views underlying an individual’s medication use. Such skills may need to be developed through specific training programmes at both undergraduate and postgraduate level.     

Pharmacist‐led medication review clinics in general practice: the views of Greater Glasgow GPs

Objectives To ascertain general practitioners' views of a pharmacist‐led medication review (PLMR) service. In particular, to quantify the percentage of GPs who perceived PLMR to be a useful service to their practices; to explore key service benefits, problems and areas for future improvement; and to quantify the percentage of GPs who believed service benefits outweighed problems. Method Semi‐structured interviews with a purposive sample of six GPs informed the development of a self‐completion postal questionnaire. The questionnaire was sent to all 258 GPs in the 82 practices where PLMR clinics were held. GP views on aspects of the PLMR process were elicited using a Likert scale. Closed questions sought views on overall service value. Free‐text responses were sought on benefits, problems and areas for future improvement. Key findings The response rate was 84% for GPs (93% of practices were represented). Ninety‐five per cent of respondents considered PLMR to be a useful service. Key perceived benefits (improved prescribing practice, raised standards of patient care and satisfaction, and increased GP knowledge and confidence) outweighed problems (space and time constraints, limited GP‐pharmacist contact, occasional patient dissatisfaction). Only a minority of GPs felt that the written pharmacy referrals relating to specific patients were inappropriate. Views were divided as to whether PLMR increased or decreased practice workload. Suggestions for future improvements included increased GP‐pharmacist communication and extended pharmacist roles. Conclusion The Glasgow model of PLMR deployed across a large Primary Care Trust by a team of pharmacists was viewed by those GPs who had received input as a useful service. The majority of GPs exposed to the service believed benefits outweighed problems.     

Knowledge,attitudes and beliefs of patients and carers regarding medication adherence: a review of qualitative literature

Purpose

The aim of this review is to cohere evidence on the knowledge, attitudes and beliefs of patients and carers regarding medication adherence. Medication adherence refers to “the extent to which the patient’s action matches the agreed recommendations”. Medication adherence is vital in preventing, managing and curing illnesses and, hence, is linked with positive health outcomes.

Methods

A search was conducted using the following databases: CINAHL, Embase, PubMed and Web of Knowledge from inception to November 2013. Titles and abstracts were screened for inclusion in the review according to pre-defined inclusion and exclusion criteria. Studies were assessed for quality, and data were extracted into a data extraction form. Results were analysed thematically.

Results

The final results included 34 articles. Eight analytical themes were identified: (i) beliefs and experiences of medicines, (ii) family support and culture, (iii) role of and relationship with health-care practitioners, (iv) factors related to the disease, (v) self-regulation, (vi) communication, (vii) cost and (viii) access. The theme, “beliefs and experiences of medicines”, was present in 33 studies, with many discussing the influence that side effects have on medication adherence.

Conclusions

There are a number of variables that impact upon the knowledge, attitudes and beliefs of patients and carers regarding medication adherence. This review presents an overview of the analytical themes which offers the opportunity to examine interventions and their relative efficacies to increase medication adherence.     

Overcoming obstacles for adherence to phosphate binding medication in dialysis patients: a qualitative study

Objective The aim of this study was to explore obstacles to adherence to phosphate binding medication and to describe the measures taken by dialysis patients to overcome these obstacles. Setting A Swedish renal unit. Method Ten patients undergoing dialysis were interviewed. The interviews were semi-structured and were analysed according to qualitative content analysis. Main outcome measure Statements about barriers and the ways to overcome these. Results Non user-friendly drug compound, feeling of discomfort, forgetfulness, polypharmacy and patient ignorance were identified as obstacles to adherence to phosphate binding medication. Measures taken by the patients to handle obstacles were identified as using a dispensing aid, consuming extra water and exercising routines. Conclusion Dialysis patients identify obstacles that impede patient adherence to prescribed phosphate binding medication. The patients overcame most obstacles by self-management but not always in concordance with treatment requirements. Our findings imply that the ways the patient conquer each barrier need to be considered when strategies for self-management are promoted.