What are validated self-report adherence scales really measuring?: a systematic review

Aims

Medication non-adherence is a significant health problem. There are numerous methods for measuring adherence, but no single method performs well on all criteria. The purpose of this systematic review is to (i) identify self-report medication adherence scales that have been correlated with comparison measures of medication-taking behaviour, (ii) assess how these scales measure adherence and (iii) explore how these adherence scales have been validated.

Methods

Cinahl and PubMed databases were used to search articles written in English on the development or validation of medication adherence scales dating to August 2012. The search terms used were medication adherence, medication non-adherence, medication compliance and names of each scale. Data such as barriers identified and validation comparison measures were extracted and compared.

Results

Sixty articles were included in the review, which consisted of 43 adherence scales. Adherence scales include items that either elicit information regarding the patient''s medication-taking behaviour and/or attempts to identify barriers to good medication-taking behaviour or beliefs associated with adherence. The validation strategies employed depended on whether the focus of the scale was to measure medication-taking behaviour or identify barriers or beliefs.

Conclusions

Supporting patients to be adherent requires information on their medication-taking behaviour, barriers to adherence and beliefs about medicines. Adherence scales have the potential to explore these aspects of adherence, but currently there has been a greater focus on measuring medication-taking behaviour. Selecting the ‘right’ adherence scale(s) requires consideration of what needs to be measured and how (and in whom) the scale has been validated.     

The association of health literacy with illness perceptions,medication beliefs,and medication adherence among individuals with type 2 diabetes

Background

Beliefs in medications and illness perceptions is associated with medication adherence among individuals with diabetes and several adherence interventions focus on patients' beliefs in medicines and illnesses. Though health literacy is important in medication adherence, the relationship between health literacy and medication adherence remains inconclusive; thus raising the question as to whether health literacy has an amplifying or reducing effect on the relationship between beliefs and adherence.

Lazy Sunday afternoons: the negative impact of interruptions in patients’ daily routine on adherence to oral antidiabetic medication. A multilevel analysis of electronic monitoring data

Purpose

Considerable variability in adherence over time exists. The aim of this study was to investigate to what extent deviations from the prescribed regimen in type 2 diabetes patients can be explained by characteristics of the individual ‘medication intake moments’ and the patient.

Methods

Medication intake of 104 non-adherent type 2 diabetes patients from 37 community pharmacies was electronically monitored for 6 months. The primary outcome measures were: (1) whether or not the intake occurred and (2) whether or not the intake occurred within the agreed-upon time period (correct timing). Multilevel logistic regression analyses were performed to account for the nested structure of the data.

Results

Medication intakes in the evening and during weekends and holidays were more likely to be incorrectly timed and also more likely to be completely missed. Irrespective of timing, most intakes occurred in the mornings of Monday through Thursday (96 %), and least intakes occurred on Saturday evening (82 %). Correctly timed intakes most often occurred on Monday and Tuesday mornings (61 %) in contrast to Sunday evenings (33 %). A patient’s medication regimen was significantly associated with adherence.

Conclusion

Based on our results, among patients who already have difficulties in taking their oral antidiabetic medication, interruptions in the daily routine negatively influence the intake of their medication. Professionals need to be aware of this variation in adherence within patients. As regular medication intake is important to maintain glycaemic control, healthcare professionals and patients should work together to find strategies that prevent deviations from the prescribed regimen at these problematic dosing times.     

Assessment of adherence to cardiovascular medicines in rural population: An observational study in patients attending a tertiary care hospital

Introduction:

Nonadherence to cardiovascular medicines is a major concern. It increases the morbidity and mortality of cardiovascular patients. The work was conducted to evaluate the adherence to cardiovascular medicines in patients of rural India.

Methods:

The study was conducted in the Department of Medicine involving rural patients with essential hypertension (HTN), congestive cardiac failure (CCF), and ischemic heart disease (IHD) over 12 months period. Patients were prescribed with cardiovascular medicines at the initial visit and adherence to medicines was assessed in the subsequent visit. Four items Morisky''s Medication Adherence Scale (MMAS-4) was used for assessing medication adherence. Patients were considered adherent to medication if they answered negatively to all four questions.

Results:

Overall adherence to medication was 20.83%, 28.37% and 32% in HTN, CCF, and IHD patients, respectively. Nonadherence was highest in patients of HTN. Among the four reasons of nonadherence assessed by MMAS-4, carelessness was the most common and forgetfulness was the least common cause of nonadherence in all the three groups of patients.

Conclusion:

Patients of rural India adhere poorly to cardiovascular medicines. Nonadherence should be considered as a public health problem. Strategies for detecting the level of adherence of cardiovascular medicines, its barriers, and subsequent interventions should be developed by policy-makers to reduce morbidity and mortality due to cardiovascular disorders.KEY WORDS: Cardiovascular medicines, congestive cardiac failure, essential hypertension, ischemic heart disease     

Evaluation of adherence to therapy in patients of chronic kidney disease

Objective:

To evaluate adherence to medication and study factors associated with non-adherence in chronic kidney disease (CKD) patients.

Methods:

A prospective, cross-sectional, questionnaire based study was conducted in Nephrology department of a super specialty hospital. Patients above 18 years of age, suffering from CKD from six months or more were interviewed using self-designed, semi-structured questionnaire to get information about adherence to medication, diet restriction and lifestyle modification (n = 150). Morisky medication adherence questionnaire was used to calculate overall adherence. In this higher score indicates poor adherence. Main outcome measures included prevalence of non-adherence and factors associated with the same.

Results:

Average number of medicines taken by each patient was 8.0+1.612 (mean+SD) per day. Non-adherence to medication schedule was reported in 34% patients. Common causes of non-adherence were high cost (21.3%), complex dosing schedule (20%), fear of adverse effects (16%). Sixty-eight% patients were not aware about importance of taking each medicine. Sixteen% stopped taking medicines due to high cost. Forty-two% suggested that government should adopt measures to provide free medicines to poor patients. In Morisky medication adherence questionnaire high, medium and low adherence was reported in 7.3%, 55.3% and 37.3% of patients, respectively. Moderately positive correlation was observed between poor adherence and number of concurrent illnesses and number of medicines taken.

Conclusion:

Since majority of patients were not aware about importance of taking each medicine, creating awareness about the same is essential for improving adherence to therapy. Measures to provide free medicines to non-affording patients need to be implemented since high cost was other major cause of non-adherence.KEY WORDS: Medication nonadherence, morisky medication adherence questionnaire, polypharmacy in chronic kidney disease     

Potential risk factors for medication non-adherence in patients with chronic obstructive pulmonary disease (COPD)

Aims

To investigate the effect of a range of demographic and psychosocial variables on medication adherence in chronic obstructive pulmonary disease (COPD) patients managed in a secondary care setting.

Methods

A total of 173 patients with a confirmed diagnosis of COPD, recruited from an outpatient clinic in Northern Ireland, participated in the study. Data collection was carried out via face-to-face interviews and through review of patients’ medical charts. Social and demographic variables, co-morbidity, self-reported drug adherence (Morisky scale), Hospital Anxiety and Depression (HAD) scale, COPD knowledge, Health Belief Model (HBM) and self-efficacy scales were determined for each patient.

Results

Participants were aged 67?±?9.7 (mean ± SD) years, 56?% female and took a mean (SD) of 8.2?±?3.4 drugs. Low adherence with medications was present in 29.5?% of the patients. Demographic variables (gender, age, marital status, living arrangements and occupation) were not associated with adherence. A range of clinical and psychosocial variables, on the other hand, were found to be associated with medication adherence, i.e. beliefs regarding medication effectiveness, severity of COPD, smoking status, presence of co-morbid illness, depressed mood, self-efficacy, perceived susceptibility and perceived barriers within the HBM (p?P?Conclusions Adherence in COPD patients is influenced more by patients’ perception of their health and medication effectiveness, the presence of depressed mood and co-morbid illness than by demographic factors or disease severity.     

Efficacy and safety of a medication dose reminder feature in a digital health offering with the use of sensor-enabled medicines

Objectives

Over one-half of patients with chronic diseases, such as hypertension and type 2 diabetes (DM), do not take medicines as prescribed. This study assessed the efficacy and safety of “seeing” versus “not seeing” medication dose reminders regarding medication adherence and risk for overdose.

Physician beliefs and attitudes toward collaboration with community pharmacists

Background

Collaboration between pharmacists and physicians in ambulatory care clinics has been shown to improve patient outcomes. Although collaborative working relationships (CWRs) between community pharmacists and physicians have been studied, the beliefs and attitudes of physicians toward collaborating with pharmacists in this setting have yet to be described. The Theory of Reasoned Action provides a model for studying collaborative behavior. Beliefs were defined in terms of the value and expected outcomes associated with collaborating with community pharmacists.

Objective

The purpose of this study was to describe the beliefs, attitudes, and intentions of office-based physicians toward collaborating with community pharmacists to help patients manage their medications.

Methods

A cross-sectional study of Michigan office-based physicians was conducted. A total of 1109 internists, pulmonologists, endocrinologists, and cardiologists were surveyed. CWR measures, beliefs, attitudes, and intentions to collaborate were measured using a mailed survey. Regression analysis identified beliefs relevant to intentions to collaborate.

Results

There were 332 usable surveys returned (30% response rate). Overall, physicians’ beliefs and attitudes toward collaborating with community pharmacists were moderately strong. Physicians’ beliefs that collaborating with a community pharmacist would result in improved medication adherence was the strongest predictor of attitude toward collaboration. The belief that collaboration with a pharmacist would result in improved prescribing was another significant predictor. The results also found attitude toward collaboration significantly predicted intention to collaborate.

Conclusions

Physicians’ beliefs and attitudes play an important role in their intentions to collaborate with community pharmacists. The findings suggest a strategy that involves collaboration to improve medication adherence may be most effective.     

The experiences and beliefs of older people in Scottish very sheltered housing about using multi-compartment compliance aids

Background Multi-compartment compliance aids (MCAs) are promoted as a potential solution to medicines non-adherence despite the absence of high quality evidence of effectiveness of MCA use impacting medicines adherence or any clinical outcomes. Furthermore, there is a lack of qualitative research which focuses on the perspectives of older people receiving MCAs. Objectives To describe experiences and beliefs surrounding very sheltered housing (VSH) residents’ use of MCAs with emphasis on issues of personalisation, reablement, shared decision-making, independence and support. Setting VSH in north east Scotland. Methods Qualitative, face-to-face interviews with 20 residents (≥ 65 years, using MCA > 6 months) in three VSH complexes. Interviews focused on: when and why the MCA was first introduced; who was involved in making that decision; how the MCA was used; perceptions of benefit; and any difficulties encountered. Interviews were audiorecorded, transcribed and analysed using a framework approach. Main outcome measure Experiences and beliefs surrounding use of MCAs. Results Nine themes were identified: shared decision-making; independence; knowledge and awareness of why MCA had been commenced; support in medicines taking; knowledge and awareness of medicines; competent and capable to manage medicines; social aspects of carers supporting MCA use; benefits of MCAs; and drawbacks. Conclusion Experiences and beliefs are diverse and highly individual, with themes identified aligning to key strategies and policies of the Scottish Government, and other developed countries around the world, specifically personalisation shared decision making, independence, reablement and support.     

Attitudes toward different formulations of psychotropic drugs

Introduction

Attitudes toward psychotropic drug treatment are likely to be a factor in medication adherence and outcome, but preferences regarding different drug formulations have been rarely assessed.

Aim

To explore attitudes toward different drug formulations in a cross-sectional study in psychiatric patients and a comparison group of healthcare professionals.

Methods

Inpatients (n = 59, age 46 ± 14 years, 63% female) and staff members (n = 96, age 40 ± 10 years, 65% female) of a psychiatric department were surveyed using a questionnaire on attitudes toward 18 possible application forms of psychotropic drugs including newer formulations such as fast-dissolving tablets. The questionnaire asked respondents to rate each option on a 6-point scale (1 being most positive), and then state which would be their preferred form of application if (hypothetically) psychopharmacological treatment was required. Attitudes were clustered and differences between patients and healthcare providers, and the influence of gender and age, were analyzed.

Results

The attitudes towards the different drug formulations in patients and staff members were nearly identical. There was a high preference for oral applications, particularly conventional tablets and capsules. Non-invasive parenteral application forms obtained intermediate attitude ratings, whereas injections were rated significantly less favorably. Gender and age had no substantial influence on the results.

Discussion and conclusions

Attitudes toward psychotropic medications may reflect common stereotypes. The strong aversion to injections in both groups may be partly explained by pain avoidance and phobic tendencies. Given that attitudes toward treatment are likely to influence later adherence to medication long before wanted and unwanted drug effects occur, our findings should be taken into account early in the planning of psychotropic treatment. Support and/or education should be given to the patient before the first dose to encourage a positive attitude towards the planned treatment.     

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.

The association of ethnicity with electronically measured adherence to inhaled corticosteroids in children

Purpose

To investigate the association of ethnicity with objectively, electronically measured adherence to inhaled corticosteroids (ICS) in a multicultural population of children with asthma in the city of Amsterdam.

Methods

The study was designed as a prospective, observational multicenter study in which adherence to ICS and potential risk factors for adherence to ICS were measured in a cohort of Moroccan and native Dutch children with asthma. Electronic adherence measurements were performed for 3 months per patient using a Real Time Medication Monitoring (RTMM) system. Ethnicity and other potential risk factors, such as socio-economic status, asthma control and parental medication beliefs, were extracted from medical records or parent interviews. The association between adherence and ethnicity was analysed using multivariate linear regression analysis.

Results

A total of 90 children (aged 1–11 years) were included in the study and data of 87 children were used for analysis. Average adherence to ICS was 49.3 %. Native Dutch children showed higher adherence to ICS than Moroccan children (55.9 vs. 42.5 %, respectively; p?=?0.044, univariate analysis). After correction for confounders (>3 annual visits to the paediatric outpatient clinic, regular use of a spacer during inhalation), the final regression model showed that ethnicity was independently associated with adherence (p?=?0.028).

Conclusions

In our Western European population of inner city children with asthma, poor adherence to ICS was a serious problem, and even somewhat more so in ethnic minorities. Paediatricians involved in asthma treatment should be aware of these cultural differences in medication-taking behaviour, but further studies are needed to elucidate the causal mechanism.

     

Structured pharmacist-led intervention programme to improve medication adherence in COPD patients: A randomized controlled study

Background

COPD is characterised by a progressive airflow limitation in the lungs. However, adherence to therapy improves management of symptoms and delays disease progression. Therefore, patients' knowledge and awareness about the disease are important. Hence, pharmacist-led educational interventions could achieve this and improve medication adherence.

Prevalence and reasons for non-adherence to hyperlipidemia treatment

Aim

To assess the prevalence of medication non-adherence, and to assess the effect of selected patient-, doctor-, and therapyrelated factors on patient adherence to hyperlipidemia treatment.

Methods

Open-label questionnaire study in the primary care patients diagnosed with hyperlipidemia.

Results

A total of 255 outpatients aged 60.2 +/? 10.3 (mean +/? SD) were enrolled. Only 61.6% of patients claimed to be fully adherent during the last week. The major source of motivation to take medication was expectation to lower cholesterol level, and only extremely infrequently (2.7%) — to prolong life. Patients often pointed at economic constrains as a reason for low adherence. Getting information from doctor about the purpose of therapy (OR=3.04, 95%CI 1.36–6.80, P<0.01), understanding the purpose of therapy (OR=5.09, 95%CI 1.30–19,90, P<0.05), reading the patient information leaflet (OR=3.37, 95%CI 1.78–6.36, P<0.001), positive opinion about the effectiveness of the treatment (OR=2.45, 95%CI 1.24–4.81, P<0.01), and visiting primary care once a month (OR=2.22, 95%CI 1.05–4.69, P<0.05) were associated with adherence to the treatment.

Conclusions

Non-adherence to lipid-lowering medication is a frequent problem. This study suggests that effective doctor-patient communication may play an important role in rising patients’ motivation to systematic treatment. Better adherence might be also obtained with prescribing more affordable drugs.     

A focus group study of patient’s perspective and experiences of type 2 diabetes and its management in Jordan

Background

Diabetes is increasingly becoming a major health problem in Jordan and glycemic goals are often not achieved.

Use,attitudes and knowledge of medications among pregnant women: A Saudi study

Objective

Medication use during pregnancy is a major concern for most women. The aim of the present study was to assess medication use, knowledge and beliefs about medications among pregnant women in Saudi Arabia.

Methods

More than 760 pregnant women, attending the obstetric clinic, filled a semi-structured questionnaire. Data were collected about their sociodemographic background, medication use during pregnancy, medication/pregnancy risk awareness, sources of drug information and beliefs about medications.

Results

Most women had a positive attitude toward medications in general but they believed pregnant women should be more cautious regarding drug-use during pregnancy. A significant association was found between participants’ education and occupation, and beliefs about medications. In this context, well educated women and those working in a health-related career demonstrated more correct beliefs about medications. Women with health-related occupations were more knowledgeable about the life saving effect of drugs on unborn children. Women indicated inadequate provision of drug-related information from physician and pharmacist; they rely on medication pamphlet to get such information. The most frequently used drugs were paracetamol and vitamins (13.2%). Most pregnant women (59.2%) were able to identify drugs to-be avoided in pregnancy that agreed roughly with FDA categories with 23 hits out of 32. They indicated that newborn anomalies (6.5%) were not attributed to drug-use during pregnancy.

Conclusion

During pregnancy, women were more conservative and skeptic toward medication, health-care professionals should be aware of such attitudes when advising pregnant women to take medication.