Adaptation and validation study of the Beliefs about Medicines Questionnaire in psychiatric outpatients in a community mental health setting

Validated medication adherence questionnaires and associated factors in chronic patients: Systematic review

OBJECTIVE

To identify validated questionnaires to assess medication adherence, and its associated factors, in adult patients with chronic pathologies.

METHOD

A systematic review of scientific publications that describe validated medication adherence questionnaires in PubMed and Scopus was carried out during May 2022. The search strategy combined the MeSH Heading "Medication adherence" with the keywords: "Questionnaire" and "Validation"; adding "Spanish" to rescue questionnaires in our language. Systematic reviews, meta-analyses or scientific articles with full text available in Spanish or English were selected; published from January 2000 to April 2022; that present the application and validation of a medication adherence questionnaire in adults with chronic pathologies; and publications of the initial validation of a questionnaire, recovered through bibliographic citations of the previously identified publications, even if they are prior to the year 2000. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to represent the search process, inclusion and exclusion of the retrieved publications.

RESULTS

Ninety-seven records in PubMed and 3 adding "Spanish" were retrieved; in Scopus, 334 records were retrieved and 13 with "Spanish". One hundred-eighteen records were retrieved through bibliographic citations identification. From the analysis of the previous publications, 14 validated questionnaires were identified that assess medication adherence and are applied in English and/or Spanish in adult patients with chronic pathologies. For each questionnaire, the following characteristics were described: name, authors, year of publication, dimensions (barriers and facilitators factors), number and wording of the items, response scale, form of administration, language and pathologies of the initial validation. Of the subsequent validations, only those carried out in English and/or Spanish were presented. So far, 6 questionnaires were validated in Spanish and only for certain chronic pathologies.

CONCLUSIONS

14 validated questionnaires were identified, 6 of them were validated in Spanish. They are designed to evaluate medication adherence in a comprehensive manner, being useful to be applied in hospital and community pharmaceutical services. This review provides health professionals with tools to develop and validate their own questionnaire, adapting the wording to the local language and context of the health system.

[Translated article] Validated questionnaires on medication adherence and associated factors in chronic patients: A systematic review

OBJECTIVE

To identify validated questionnaires to assess medication adherence, and its associated factors, in adult patients with chronic pathologies.

METHOD

A systematic review of scientific publications that describe validated medication adherence questionnaires in PubMed and Scopus was carried out during May 2022. The search strategy combined the MeSH heading "Medication adherence" with the keywords: "Questionnaire" and "Validation"; adding "Spanish" to rescue questionnaires in our language. Systematic reviews, meta-analyses, or scientific articles with full text available in Spanish or English were selected; published from January 2000 to April 2022; that present the application and validation of a medication adherence questionnaire in adults with chronic pathologies; and publications of the initial validation of a questionnaire, recovered through bibliographic citations of the previously identified publications, even if they are prior to the year 2000. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to represent the search process, inclusion and exclusion of the retrieved publications.

RESULTS

(97) records in PubMed and 3 adding "Spanish" were retrieved; in Scopus, 334 records were retrieved and 13 with "Spanish". 118 records were retrieved through bibliographic citations identification. From the analysis of the previous publications, 14 validated questionnaires were identified that assess medication adherence and are applied in English and/or Spanish in adult patients with chronic pathologies. For each questionnaire, the following characteristics were described: name, authors, year of publication, dimensions (barriers and facilitators factors), number and wording of the items, response scale, form of administration, language, and pathologies of the initial validation. Of the subsequent validations, only those carried out in English and/or Spanish were presented. So far, 6 questionnaires were validated in Spanish and only for certain chronic pathologies.

CONCLUSIONS

(14) validated questionnaires were identified, 6 of them were validated in Spanish. They are designed to evaluate medication adherence in a comprehensive manner, being useful to be applied in hospital and community pharmaceutical services. This review provides health professionals with tools to develop and validate their own questionnaire, adapting the wording to the local language and context of the health system.

Effectiveness of interventions to improve adherence to antidepressant medication in patients with depressive disorders: a cluster randomized controlled trial

Aim

To assess the effectiveness of two interventions of knowledge transfer and behavior modification to improve medication adherence in patients with depressive disorders.

Methods

An open, multicenter, three-arm clinical trial with random allocation by cluster to usual care or to one of the two interventions. The intervention for psychiatrists (PsI) included an educational program based on a patient-centered care model. The intervention for patients and relatives (PtI) included a collaborative care program plus a reminder system that works using an already available medication reminder application. The primary outcome was patient adherence to antidepressant treatment assessed through the Sidorkiewicz Adherence Instrument. Secondary measures were depression severity, comorbid anxiety and health-related quality of life. Mixed regression models with repeated measures were used for data analysis.

Results

Ten psychiatrists and 150 patients diagnosed with depressive disorder from eight Community Mental Health Units in the Canary Islands (Spain) were included. Compared with usual care, no differences in long-term adherence were observed in either group PsI or PtI. The PsI group had significantly improved depression symptoms (B = -0.39; 95%CI: -0.65, -0.12; p = 0.004) during the follow-up period. The PtI group presented improved depression symptoms (B = -0.63; 95%CI: -0.96, -0.30; p < 0.001) and mental quality of life (B = 0.08; 95%CI: 0.004, 0.15; p = 0.039) during the follow-up period.

Conclusion

The assessed interventions to improve adherence in patients with depressive disorder were effective for depression symptoms and mental quality of life, even over the long term. However, no effect on antidepressant adherence was observed.

Nonadherence after hospital discharge in patients with schizophrenia or schizoaffective disorder: A six-month naturalistic follow-up study

BACKGROUND

Despite a wealth of studies seeking to identify factors associated with nonadherence few consistent predictors have been determined, and several gaps still exist in the literature.

METHOD

We assessed 110 consecutively admitted patients diagnosed with schizophrenia or schizoaffective disorder according to ICD-10 criteria. Assessments were performed during hospitalization and at six-months follow-up. Evaluation included sociodemographic, clinical, psychopathologic and treatment-related variables. Prevalence of nonadherence, associated variables, reasons for nonadherence and possible subtypes were explored. Adherence was defined as the concurrence of adherence to antipsychotic treatment and adherence to outpatient follow-up, during the six-month period.

RESULTS

Nonadherence was detected in 58.2% of patients. An identifiable profile was found in nonadherent patients. After multivariate logistic regression analysis, low socio-economic level (OR = 3.68; 95% CI = 1.42-9.53), current cannabis use or abuse (OR = 2.79; 95% CI = 1.07-7.28), nonadherence as a reason for relapse and admission (OR = 5.46; 95% CI = 2.00-14.90), and greater overall severity of symptoms at six months follow-up (OR = 2.00; 95% CI = 1.02-3.95) remained independently associated with nonadherence. Believing that medication is unnecessary was the most reported reason for nonadherence. For nonadherent patients (N = 64), two distinguishable subtypes were found: intentional nonadherence (N = 32; 50%), and unintentional nonadherence (N = 32; 50%).

CONCLUSIONS

A large percentage of patients with schizophrenia or schizoaffective disorder did not adhere to their treatment in the post-discharge follow-up period. The profile identified may enable better prevention of this problem. Specific reasons for nonadherence should also be explored to provide individualized strategies.

Effect of necessity-concern framework and polypharmacy on treatment adherence in psychiatric patients. Comparing an Argentinian with a Spanish sample

OBJECTIVE

We aimed to replicate a prior Spanish study of medication adherence where logistic regression models provided highly significant odds ratios (ORs) for three continuous scores: necessity, concern and the necessity-concern differential, and a dichotomous variable: skeptical attitude. Adherence ORs in the necessity-concern framework were very strong in patients taking five or six medications.

METHODS

The sample comprised consecutive adult psychiatric outpatients in Mendoza, Argentina. The necessity-concerns framework was assessed using a subscale of the Beliefs about Medicines Questionnaire. Adherence (yes/no) to prescribed psychiatric medications was assessed by the Sidorkiewicz adherence tool.

RESULTS

When compared with the Spanish sample, the Argentinian group (508 patients with 875 medications) was characterized by: (1) significantly stronger adherence ORs with the necessity-concern framework, (2) significantly lower number of medications per patient and percentage of patients with marked psychiatric polypharmacy (≥4 medications), (3) though a higher number of medications still was significantly associated with poor adherence.

CONCLUSIONS

The Argentinian sample replicated the previous finding that patient beliefs regarding necessity and concern were associated with poor adherence to prescribed medications. Polypharmacy had an additive role decreasing adherence in both samples. In both samples, when prescribed ≥4 psychiatric medications, patients reported adherence to only two-third of the medications.

Beliefs about medicines and adherence in women with breast cancer on adjuvant endocrine therapy

The Beliefs about Medicines Questionnaire (BMQ) and Adherence Starts with Knowledge (ASK-12) questionnaire were originally developed and validated in Western populations to assess beliefs and barriers to medication adherence. The study aim is to validate the BMQ and ASK-12 questionnaire for use in a Singapore population with early stage breast cancer. English-speaking women on adjuvant endocrine therapy (n = 157) were recruited. The BMQ-Specific showed good internal consistency with structural validity. The internal consistency of BMQ-General and ASK-12 Behaviour scale improved with the new factor structure obtained from exploratory factor analysis. Further studies are needed to confirm these factor structures.

Validation of the Swedish version of the Beliefs about Medicines Questionnaire, based on people with epilepsy

TITLE

Validation of the Swedish version of the Beliefs about Medicines Questionnaire, based on people with epilepsy.

PURPOSE

The aims of the study were to explore the latent structure of the Swedish Beliefs about Medicines Questionnaire (BMQ), to investigate its reliability and to identify the extent to which individual factors among people with epilepsy (PWE), as well as their general beliefs about medication, predict their beliefs about their specific anti-seizure drugs (ASDs).

METHODS

One-hundred and fifty six included study participants diagnosed with epilepsy and with a well-established neurological follow-up completed an array of rating scales. Included were the Swedish BMQ, which captures beliefs about medicines, scales for symptoms of anxiety and depression and sense of self-efficacy, as well as a general questionnaire regarding their social situation in general. Statistical analysis included Principal Component Analyses (PCA) and hierarchical multiple regression analysis.

RESULTS

The PCA revealed a two-factor structure for each of the BMQ-subscales with acceptable (BMQ-G) to high (BMQ-S) internal consistency. The only individual factor that predicted variance in beliefs about medication was patient gender, where levels of both anxiety and depression were elevated in women.

CONCLUSION

The Swedish BMQ exhibits psychometric features indicating its reliable use in adult PWE. Our results suggest that the BMQ provides information about the patients' view of their medication regardless of their general mood and that women hold stronger beliefs of concern beyond influence from their levels of depression and anxiety.

Validez y confiabilidad del Beliefs About Medicines Questionnaire en pacientes hipertensos colombianos

Introducción. El Beliefs about Medicines Questionnaire (BMQ) permite valorar las representaciones cognitivas que engloban las creencias sobre la medicación de los pacientes, sobre tomar medicamentos para su enfermedad en diferentes culturas. Objetivo. Determinar la validez de constructo y confiabilidad del cuestionario BMQ adaptado a pacientes hipertensos colombianos. Materiales y métodos. Estudio psicométrico de tipo instrumental, realizado en una muestra de 238 pacientes hipertensos en edad promedio de 65 años (DE= 11,4) con predominio del sexo femenino (70%). La validez de constructo se evaluó mediante Análisis Factorial Exploratorio y Confirmatorio. Se calculó la confiabilidad utilizando el método coeficiente de alfa de Cronbach. Resultados. Se obtuvo una versión reducida de 16 ítems; en la sección BMQ-General los 7 ítems se agruparon en dos factores que explicó el 64% de la varianza común y buen ajuste ( = 61.46; gl = 13; p = 0.000; CFI = 0.917; NNFI = 0.89; CFI=0.917; SRMR=0.054; RMSEA = 0.125; IC 90% [0,10, 0,16]). En el BMQ-Específico los 9 ítems agrupados en dos factores que explicaron el 63,17% de la varianza común con un ajuste aceptable ( = 122.4; gl = 26; p = 0.000; CFI = 0.88; NNFI = 0.84; CFI=0.88; SRMR=0.106; RMSEA = 0.125; IC 90% [0.10, 0.15]). La confiabilidad por alfa de Cronbach para el BMQ-General y Específico fue de 0.82 y 0.78 respectivamente. Discusión y conclusiones. La versión del BMQ adaptada a pacientes hipertensos colombianos, poseen características psicométricas adecuadas, su uso es recomendado en la investigación.

Effects of a peer co-facilitated educational programme for parents of children with ADHD: a feasibility randomised controlled trial protocol

INTRODUCTION

Significant numbers of children with attention deficit hyperactivity disorder (ADHD) display problems that cause multiple disabilities, deficits and handicaps that interfere with social relationships, development and school achievement. They may have multiple problems, which strain family dynamics and influence the child's treatment. Parent activation, described as parents' knowledge, skills and confidence in dealing with their child's health and healthcare, has been shown to be an important factor in improving health outcomes. Research suggests that parents need edification to learn skills crucial to the treatment and management of their children's healthcare. Promoting positive parenting techniques may reduce negative parenting factors in families. This study aims to assess the acceptability, feasibility and estimated sample size of a randomised controlled trial (RCT) comparing an ADHD peer co-led educational programme added to treatment as usual (TAU).

METHODS AND ANALYSIS

Using a randomised waitlist controlled trial, parents of children aged 6-12 years newly diagnosed with ADHD, and referred to a child mental health outpatient clinic in Mid-Norway, will receive TAU concomitant with a peer co-facilitated parental engagement educational programme (n=25). Parents in the control group will receive TAU, and the educational programme treatment within a waitlist period of 3-6 months (n=25). Parent activation, satisfaction, well-being, quality of life and treatment adherence, will be assessed at baseline (T0), 2 weeks (T1) pre-post intervention (T2, T3) and at 3 months follow-up (T4). Shared decision making, parents preferred role in health-related decisions and involvement, parent-reported symptoms of ADHD and child's overall level of functioning will be assessed at T0 and T4. Such data will be used to calculate the required sample size for a full-scale RCT.

ETHICS AND DISSEMINATION

Approval was obtained from the Regional Committee for Medicine and Health Research Ethics in Mid-Norway (ref: 2018/1196). The findings of this study are expected to provide valuable knowledge about how to optimise family education and management of ADHD and will be disseminated through presentations at conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04010851.

The 'Necessity-Concerns Framework' as a means of understanding non-adherence by applying polynomial regression in three chronic conditions

OBJECTIVE

The 'Necessity-Concerns Framework' is an important framework which can support healthcare professionals in targeting patients' medication beliefs and decisions on adherence. Our aim was to determine how the interdependence of 'necessity' and 'concerns' beliefs for medication adherence compares across three chronic conditions.

METHODS

Patients diagnosed with asthma, cardiovascular conditions or diabetes attending out-patient clinics completed a self-administered questionnaire. The questionnaire gathered information regarding demographics, medication adherence using the 'Tool for Adherence Behaviour Screening', presence of unused medication in households and medication beliefs using the 'Beliefs about Medicines Questionnaire-Specific'. Polynomial regression was applied to determine the multidimensional interdependence of 'necessity' and 'concerns' beliefs for adherence. P-values ≤ 0.05 were taken to be significant.

RESULTS

Confirmatory polynomial regression rejected the differential score model in all three groups. For each condition, exploratory polynomial regression found that linear terms indicated the best fitting model for predicting adherence. In all groups, adherence increased as necessity beliefs increased and concerns decreased. Patients suffering from cardiovascular conditions and diabetes with low necessity and low concerns beliefs reported higher medication adherence compared to those with high necessity and high concerns beliefs.

DISCUSSION

Alleviating patients' concerns can enhance medication adherence and potentially curb the issue of medication wastage.

Testing the hypothesis of subtypes of nonadherence in schizophrenia and schizoaffective disorder: A prospective study

BACKGROUND

Nonadherence is a major problem in the treatment of psychotic disorders. It has been hypothesized that nonadherent patients with schizophrenia are not a homogeneous population and subtypes of nonadherence might exist, but this hypothesis has not been specifically tested.

AIM

To test the hypothesis of subtypes of nonadherence in schizophrenia and schizoaffective disorder.

METHODS

This prospective study included 110 consecutively admitted patients diagnosed with schizophrenia or schizoaffective disorder. Assessments were performed at baseline and at 6 mo follow-up after discharge. Sociodemographic, clinical, psychopathological and treatment-related variables were evaluated. Adherence was defined as the concurrence of adherence to antipsychotic treatment and outpatient follow-up during the six-month period. Adherence to antipsychotic treatment was defined as the concurrence of objective and subjective adherence. Sixty-four patients (58%) fulfilled nonadherence criteria at the end of the follow-up period and were categorized according to their subtype of nonadherence.

RESULTS

In nonadherent patients (n = 64), 32 (50%) fulfilled criteria of intentional nonadherence, and 32 (50%) of unintentional nonadherence (UNA). Unintentional nonadherent patients, as compared to intentional nonadherent patients, are characterized by older age, lower educational level, worse cognitive and negative symptoms, greater severity, worse knowledge of their treatment regimen, greater prevalence of supervision of the treatment, lower number of prior hospitalizations and greater use of nonpsychiatric treatment, anticholinergics and hypnotics. Low educational level (OR = 26.1; 95%CI: 2.819-241), worse treatment knowledge at six months (OR per unit = 0.904; 95%CI: 0.853-0.957) and nonpsychiatric treatment at six months (OR = 15.8; 95%CI: 1.790-139) were independently associated to UNA.

CONCLUSION

Differentiated subtypes of nonadherence according to intentionality seem to exist in patients with schizophrenia and schizoaffective disorder. Our findings suggest the need for differentiated approach, both in future research and in clinical practice.

Treatment Attitudes and Adherence Among Patients with Bipolar Disorder: A Systematic Review of Quantitative and Qualitative Studies

BACKGROUND

Systematic reviews about treatment attitudes of patients influencing adherence in bipolar disorder (BD) are rare.

METHODS

A systematic review was conducted according to the PRISMA guidelines and principles of thematic synthesis. Selectively identified quantitative and qualitative studies were used to examine the attitude-adherence relationship in BD, the types and correlates of treatment attitudes, and the impact of psychosocial interventions on attitudes.

RESULTS

The final list of 163 articles included 114 observational reports (incorporating 21 psychosocial intervention trials), 45 qualitative/descriptive studies, and 4 patient surveys. A positive association between treatment attitudes and adherence was found in most quantitative and qualitative studies, though the strength of the relationship was unclear. Thematic analysis of qualitative studies suggested that patient attitudes influencing adherence were based on perceived advantages and disadvantages of treatment. The principal correlates of patients' attitudes were family attitudes, the clinician-patient alliance, social support, and patients' knowledge of BD. Though negative attitudes such as denial, concerns about adverse treatment consequences, and stigmatizing effects of treatment were common, many patients believed treatment to be beneficial and necessary. The limited data on the effect of psychosocial interventions indicated that treatments selectively targeting attitudes enhanced adherence.

LIMITATIONS

The studies were heterogeneous in design; the quality was uneven (fair to poor); and the risk of bias moderate to high.

CONCLUSIONS

Despite these flaws, awareness of the existing evidence on the attitude-adherence association and other aspects of treatment attitudes in BD can help in efforts to address nonadherence in BD.

Adaptation and validation of the Polish version of the Beliefs about Medicines Questionnaire among cardiovascular patients and medical students

Background

The Beliefs about Medicines Questionnaire (BMQ) is the leading tool intended to assess the cognitive representation of medication, however, the validated Polish version of the questionnaire is lacking.

Aims

To adapt the original BMQ tool to the Polish language (BMQ-PL) and to validate it.

Materials and methods

The BMQ was adapted to Polish according to widely accepted guidelines. A total of 311 cardiovascular in- and outpatients as well as medical students taking chronic medication were surveyed to assess data-to-model fit and internal consistency of the measure. The criterion-related validity was determined with the use of Polish version of the Adherence to Refills and Medications Scale. Confirmatory and exploratory factor analyses were used, as well as general linear modeling.

Results

The BMQ-PL exhibited the same factorial structure as the original questionnaire and all the items loaded on their expected factors. Internal consistency of the questionnaire was satisfactory in the group of cardiovascular patients (Cronbach’s alpha ranging from 0.64 to 0.82 and McDonald’s omega from 0.90 to 0.91). There were significant correlations in the predicted directions between all BMQ-PL subscales and the measure of drug adherence in cardiovascular outpatients, but not in inpatients. Medical students may conceptualize the beliefs about medicines in a different way; as a result, a modified version of the BMQ-PL-General, suitable for medically-educated people, was proposed.

Conclusion

The BMQ-PL exhibits satisfactory proof of validity to be used among cardiovascular patients.

The necessity-concern framework in the assessment of treatment adherence of psychiatric patients and the role of polypharmacy in a Spanish sample

OBJECTIVE

This study compares three measures (necessity and concern scores, the necessity-concern differential, and a skeptical attitude vs. three other attitudes) for studying the relationship between the necessity-concern framework and treatment adherence after considering the number of prescribed drugs.

METHODS

The sample included 588 consecutive adult psychiatric outpatients in the Canary Islands, Spain. The necessity-concern framework was assessed using a specific subscale of the Beliefs about Medicines Questionnaire. Adherence (yes/no) to 1,101 prescribed psychiatric drugs was assessed using the Sidorkiewicz adherence tool.

RESULTS

In the three logistic regression models including 1,101 drugs, with adherence as the dependent variable, the highly significant odds ratios (ORs) and their 95% confidence intervals (CIs) were (a) OR = 1.57 (CI = 1.37-1.79) for necessity and OR = 0.747 (CI = 0.660-0.847) for concern; (b) OR = 1.44 (CI = 1.32-1.58) for the necessity-concern differential; and (c) OR = 0.452 (CI = 0.343-0.597) for a skeptical attitude (yes/no), defined as low necessity and high concern. In patients taking five or six drugs, adherence was associated with extremely high/low ORs for necessity, concern, and the differential.

CONCLUSION

If replicated, our results suggest clinicians need to pay careful attention to each drug in each patient taking five or six drugs, emphasize necessity, and listen carefully to patient concerns.

The Vietnamese Version of the Brief Illness Perception Questionnaire and the Beliefs about Medicines Questionnaire: Translation and Cross-cultural Adaptation

OBJECTIVE

To translate and cross-culturally adapt the Brief Illness Perception Questionnaire (BIPQ) and the Beliefs about Medicines Questionnaire (BMQ) into Vietnamese.

METHODS

We followed the guideline by Beaton et al. (2000 & 2007). Stage I: two translators (informed and uninformed) translated the questionnaires. Stage II: the translations were synthesised. Stage III: back translation was performed by two translators fluent in both Vietnamese and English but naïve to the outcome measurement. Stage IV: seven experts reached consensus on the pre-final Vietnamese version (BIPQ-V and BMQ-V). Stage V: field test of the questionnaires on 16 twelve-year-old students and 31 Vietnamese patients. In addition, we determined the internal consistency and test-retest reliability of the questionnaires in 34 Vietnamese patients with acute coronary syndrome.

RESULTS

All experts agreed that there was semantic, idiomatic, experiential and conceptual equivalence between the original and pre-final Vietnamese versions of the BIPQ and BMQ. Cronbach's alpha coefficients of the internal consistency were acceptable for the BMQ-V Specific-Necessity (0.64), BMQ-V Specific-Concerns (0.62) and BMQ-V General-Harm (0.60), with the exception of BMQ-V General-Overuse (0.27). Intra-class correlation coefficients of the test-retest reliability were acceptable for the subscales of BMQ-V (range: 0.77-0.86), and BIPQ-V items (range: 0.62-0.85) with the exception of BIPQ-V 1 (0.44, 95% CI -014 to 0.72) and BIPQ-V 4 (0.57, 95% CI 0.22-0.81).

CONCLUSIONS

The Vietnamese version of BIPQ and BMQ are reliable tools to assess illness perceptions and beliefs about medicines of patients with acute coronary syndrome. Psychometric properties of these questionnaires should be tested in different patient populations.

Randomised controlled trial of a video intervention and behaviour contract to improve medication adherence after renal transplantation: the VECTOR study protocol

INTRODUCTION

Non-adherence after kidney transplantation contributes to increased rejections, hospitalisations and healthcare expenditures. Although effective adherence interventions are sorely needed, increasing education and support to transplant recipients demands greater use of care providers' time and resources in a healthcare system that is stretched. The objective of this clinical trial is to determine the effectiveness of an electronically delivered video series and adherence behaviour contract on improving medication adherence to immunosuppressant medications.

METHODS AND ANALYSIS

A multicentre, parallel arm, randomised controlled trial will be conducted with four sites across North America (Saskatoon, Calgary, Halifax, Chicago). Adult patients will be randomised (1:1) to either the intervention (ie, home-based video education +behaviour contract plus usual care) or usual care alone. De novo transplant recipients will be enrolled prior to their hospital discharge and will be provided with electronic access to the video intervention (immediately) and adherence contract (1 month post-transplant). Follow-up electronic surveys will be provided at 3 and 12 months postenrolment. The primary outcome will be adherence at 12 months post-transplant, as measured by self-report Basel Assessment of Adherence to Immunosuppressive medications and immunosuppressant levels. Secondary outcomes include the difference in knowledge score between the intervention and control in groups (measured by the Kidney Transplant Understanding Tool); differences in self-efficacy (Generalised Self-efficacy Scale), Beliefs of Medicine Questionnaire (BMQ), quality of life (Short Form-12), patient satisfaction and cost utilisation. The study aims to recruit at least 200 participants across participating sites.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Saskatchewan Behavioural Ethics Committee (Beh 18-63), and all patients provide informed consent prior to participating. This educational intervention aims to improve information retention and self-efficacy, leading to improved medication adherence after kidney transplantation, at low cost, with little impact to existing healthcare personnel. If proven beneficial, delivery can be easily implemented into standard of care.

TRIAL REGISTRATION NUMBER

NCT03540121; Pre-results.

Ethnopsychopharmacology study of patients' beliefs regarding concerns about and necessity of taking psychiatric medications

OBJECTIVE

The aim of this study was to examine whether or not cultural differences influence beliefs about the necessity of taking prescribed psychiatric drugs and concern about their adverse effects in psychiatric outpatients in Spain, Argentina, and Venezuela.

METHODS

This cross-sectional study included 1,372 adult psychiatric outpatients using 2,438 psychotropic drugs and was designed to assess outpatients' beliefs about their prescribed medication. Patients completed sociodemographic, clinical questionnaires, and the Beliefs about Medicines Questionnaire Specific Scale and registered scores ranging from 1 to 5 on each of two subscales: concern and necessity. A "necessity-concern differential" was obtained by calculating the difference (range -4 to +4).

RESULTS

The global score, including all drugs in the total sample, had a mean necessity score of 3.50 ± 0.95, a mean concern score of 2.97 ± 0.99, and a mean differential score of 0.54 ± 1.42. The concern and necessity mean scores varied significantly across these three culturally Hispanic countries, probably across drug classes, and were associated with treatment duration. On the other hand, age and education played a very limited role.

CONCLUSIONS

Understanding the diverse effects of culture and society on these attitudes is highly relevant for the development of responsive mental health services in multicultural societies.

Effectiveness and cost-effectiveness of a multicomponent intervention to improve medication adherence in people with depressive disorders - MAPDep: a study protocol for a cluster randomized controlled trial

PURPOSE

Depression is a widespread mental disorder which can be treated effectively. However, low adherence to antidepressants is very common. The study of medication adherence in depression (MAPDep study) assesses the effectiveness and cost-effectiveness of a multicomponent strategy to enhance adherence toward medications in patients with depression.

INTERVENTION

The intervention is a multicomponent one consisting of an educational program for psychiatrists and/or a collaborative care program for patients and relatives, plus a reminder system that works through the use of an already available high-quality medication reminder application.

STUDY DESIGN

MAPDep study is an open, multicenter, four-arm cluster randomized controlled trial. The clusters are mental health units where psychiatrists are invited to participate. The clusters are randomly allocated to one of the three interventions or to usual care (control arm). Patients (18-65 years of age) diagnosed with depressive disorder, those taking antidepressant medication for an existing diagnosis of depression, and mobile phone users are selected. In group 1, only patients and relatives receive intervention; in group 2, only psychiatrists receive intervention; and in group 3, patients/relatives and psychiatrists receive intervention. The primary outcome is adherence to the antidepressant drug. The calculated sample size is 400 patients. To examine changes across time, generalized linear mixed model with repeated measures will be used. A cost-effectiveness analysis will be conducted. The effectiveness measure is quality-adjusted life years. Deterministic sensitivity analyses are planned.

CONCLUSION

MAPDep study aims to assess a multicomponent strategy to improve adherence toward medications in patients with depression, based not only on clinical effectiveness but also on cost-effectiveness. This methodology will enhance the transferability of the expected results beyond mental health services (patients and psychiatrists) to health care policy decision making.

CLINICAL TRIAL IDENTIFIER

NCT03668457.

Predictive validity of the Sidorkiewicz instrument in Spanish: Assessing individual drug adherence in psychiatric patients

Background/Objective: Concomitant prescription of two or more psychiatric medications has become the rule and patients could adhere differently to their various drugs prescribed. Sidorkiewicz et al. published a questionnaire for assessing adherence to each specific drug. Method: This study explored the predictive validity of the Spanish version of the Sidorkiewicz questionnaire in a sample of 470 consecutive psychiatric outpatients using 897 psychiatric drugs. Results: The questionnaire showed adequate predictive validity in both univariate and multivariate analyses (logistic regression and CHAID segmentation) since they demonstrated a significant association with the 10-item Drug Attitude Inventory and with the Necessity and Concern Scales of the Beliefs about Medications Questionnaire. Some demographic and clinical variables were significant in the univariate analyses but lost significance in the multivariate analyses. Conclusions: The adherence of the psychiatric patient to his/her prescribed treatment may not be significantly influenced by socio-demographic or clinical characteristics, but rather by attitudes toward medication, perceptions of personal necessity for medication, and concerns about its potential adverse effects. This study's findings suggest that the Spanish version of the Sidorkiewicz questionnaire may be a useful and valid instrument for assessing adherence to each individual drug taken by psychiatric outpatients undergoing polypsychopharmacy.

Skepticism and pharmacophobia toward medication may negatively impact adherence to psychiatric medications: a comparison among outpatient samples recruited in Spain, Argentina, and Venezuela

BACKGROUND

Cultural differences in attitudes toward psychiatric medications influence medication adherence but transcultural studies are missing. The objective of this study was to investigate how attitudes and beliefs toward psychotropic medications influence treatment adherence in psychiatric outpatients in Spain, Argentina, and Venezuela.

METHODS

A cross-sectional, cross-cultural psychopharmacology study was designed to assess psychiatric outpatients' attitudes toward their prescribed medication. Patients completed the Drug Attitude Inventory - 10 Item (DAI-10), the Beliefs about Medicines Questionnaire - Specific Scale (BMQ-Specific), the Sidorkiewicz adherence tool, and sociodemographic and clinical questionnaires. The study included 1,291 adult psychiatric outpatients using 2,308 psychotropic drugs from three Spanish-speaking countries, the Canary Islands (Spain) (N=588 patients), Argentina (N=508), and Venezuela (N=195).

RESULTS

The univariate analyses showed different mean scores on the DAI-10 and the BMQ - Necessity and Concerns subscales but, on the other hand, the percentages of non-adherent and skeptical patients were relatively similar in three countries. Argentinian patients had a very low level of pharmacophobia. Multivariate analyses (logistic regression and chi-squared automatic interaction detector segmentation) showed that pharmacophobia in general and skepticism about specific medications (high concern about adverse reactions and low belief in their necessity) were associated with non-adherence. Pharmacophobia was the major factor associated with non-adherence (Spain and Venezuela) but when pharmacophobia was rare (Argentina), skepticism was the most important variable associated with non-adherence.

CONCLUSION

Psychiatric patients' attitudes and beliefs about their psychiatric treatment varied in these three Spanish-speaking countries, but pharmacophobia and skepticism appeared to play a consistent role in lack of adherence.

Psychometric properties of the Beliefs about Medicine Questionnaire-adjuvant endocrine therapy (BMQ-AET) for women taking AETs following early-stage breast cancer

This study evaluated the Beliefs about Medicine Questionnaire to explore adherence to adjuvant endocrine therapy after treatment for breast cancer (BMQ-AET). Factor structure of the BMQ-AET was explored alongside internal consistency, convergent validity and acceptability. The BMQ-AET Specific Scale fitted the original 10 item model. Internal consistency of the BMQ-AET was much improved compared to the original BMQ and convergent validity showed predicted direction of correlation, although correlation with BMQ-AET concerns scale was low. Acceptability was good. The evaluation of the BMQ-AET is encouraging, and could facilitate future research around adherence to AET.

Psychometric properties of the Belief about Medicines Questionnaire (BMQ) in the Maltese language

BACKGROUND

Investigating beliefs about medicines has been of interest over the past years, with studies aiming to better understand theoretical reasons behind development of such beliefs.

OBJECTIVE

This study aimed to produce a culturally and contextually appropriate version of the Beliefs about Medicines Questionnaire (BMQ) in the Maltese language and to assess its psychometric properties.

METHODS

Medication beliefs were evaluated using the BMQ which is divided into two sections: BMQ-General (sub-scales: Overuse and Harm, 4 items per sub-scale) and BMQ-Specific (sub-scales: Necessity and Concerns, 5 items per sub-scale). Following translation/back translation, the Maltese version of the BMQ was applied to patients having asthma, diabetes, cardiovascular disease or depression who attended out-patients' clinics at the main state general hospital in Malta between June and September 2013. Cronbach's alpha coefficient, alpha, was used to determine internal consistency of the BMQ and Principal Component Analysis using Varimax rotation with Kaiser normalisation was carried out to analyse component loading of the items on the respective sub-scales.

RESULTS

The Maltese version of the BMQ showed acceptable internal consistency for the harm scale (alpha=0.56), the necessity scale (alpha=0.73) and the concerns scale (alpha=0.66), however the overuse scale gave poor internal consistency (alpha=0.48) due to the item on natural remedies which posed some difficulty in the Maltese sample. The final solution for Principal Component Analysis yielded a four-factor structure representing the 4 sub-scales of the BMQ, with results being comparable to previous studies out in different languages.

CONCLUSION

The Maltese version of the BMQ was found to have acceptable psychometric properties for the beliefs about medicines in the Maltese population.

Exploratory analysis of the French version of the beliefs about medicines questionnaire in patients with severe mental disorders: Factorial structure and reliability in specific populations of schizophrenic, bipolar and depressive patients

OBJECTIVES

The aims of our study were to explore the factor structure and psychometric properties of the French version of the Beliefs about Medicines Questionnaire (BMQ) in patients with severe mental illness and in specific populations of patients with schizophrenia, bipolar disorder and major depressive disorder.

METHODS

A cross-sectional study including patients with schizophrenia, bipolar disorder and major depressive disorder was conducted (n = 150). Principal component analysis (PCA), reliability and validity of the French version of the BMQ were performed.

RESULTS

PCA revealed a two-factor structure similar to the original structure for the BMQ-Specific scale but only a one-component solution for the BMQ-General scale in both the total sample and the three subgroups. These subscales have satisfactory internal consistency. Validity was supported by the significant correlations of all BMQ subscales with the Drug Attitude Inventory.

CONCLUSION

The French version of the BMQ appears as a three-dimensional scale and presents satisfactory psychometric properties for use in patients with severe mental illness as well as specific populations of patients with schizophrenia, bipolar disorder and major depressive disorder.

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.

Examining Adherence Among Challenging Patients in Public and Private HIV Care in Argentina

Treatment engagement, retention and adherence to care are required for optimal HIV outcomes. Yet, patients may fall below the treatment recommendations for achieving undetectable viral load or not be retained in care. This study examined the most challenging patients in Buenos Aires, Argentina, those non-adherent to HIV care. Men (n = 61) and women (n = 59) prescribed antiretrovirals (ARVs) and non-adherent to treatment in the prior 3-6 months were enrolled and assessed regarding adherence, knowledge, motivation and attitudes regarding treatment. Private clinic patients had lower viral load and higher self-reported adherence than public clinic patients. Motivations to be adherent and positive beliefs regarding ARVs were associated with increased adherence in public clinic participants. Increased self-efficacy was associated with increased adherence among participants from both clinics. Results support patient and provider interventions that strengthen the characteristics supporting adherence, engagement and retention in public and private clinic settings.

Association between concomitant psychiatric drug use, and patients' beliefs about and persistence with chronic cardiovascular medication

OBJECTIVE

Psychiatric disorders are associated with an increased risk of cardiovascular diseases and may result in additional risk of non-adherence. No data on the influence of concomitant psychiatric drug use on patients' beliefs and persistence related to cardiovascular medication are available. The objective of this study was to assess to what extent the use of concomitant psychiatric drugs is associated with patients' beliefs about and persistence with chronic cardiovascular medication.

METHODS

An observational study in patients using cardiovascular medication was conducted. A mailed questionnaire containing socio-demographical questions and a measure of beliefs about medication (Beliefs about Medicines Questionnaire - specific) was sent to patients selected from fifteen participating pharmacies. Persistence was evaluated based on pharmacy records.

RESULTS

Of the 1547 included patients, 551 responded to key questions in the questionnaire and were included for beliefs about medication analysis. In concomitant users of psychiatric drugs significantly higher necessity (17.0 vs. 16.0) and higher concerns (14.3 vs. 13.3), as well as higher proportion of ambivalent (34.5% vs. 25.6%) and lower proportion of indifferent patients (24.1% vs. 33.0%) were found compared with non-users (p < 0.05). 65.2% (n = 1009) of patients were persistent on all their cardiovascular drugs. There was no significant association between concomitant use of psychiatric drugs and non-persistence (OR = 1.2; 95% CI 0.9-1.5).

CONCLUSION

Concomitant use of psychiatric drugs was found to be associated with increased beliefs about the necessity of and concerns about cardiovascular medication. Clinicians caring for cardiovascular patients should give additional attention to identifying patients' beliefs about medication among those concomitantly using psychiatric drugs.

Lost in translation?: Comparing three Scandinavian translations of the Beliefs about Medicines Questionnaire

OBJECTIVE

The "Beliefs about Medicines Questionnaire" (BMQ) assess balance of necessity and concern of medicines. The BMQ has been translated from English to many languages. However, the original meaning of statements, such as "My medicine is a mystery to me", may be lost in translation. The aim of this study is to compare three Scandinavian translations of the BMQ. (1) How reliable are the translations? (2) Are they still valid after translation?

METHODS

Translated Norwegian, Swedish and Danish versions of the BMQ were scrutinized by three native Scandinavian researchers. Linguistic differences and ambiguities in the 5-point Likert scale and the BMQ statements were compared.

RESULTS

In the Scandinavian translations, the Likert scale expanded beyond the original version at one endpoint (Swedish) or both endpoints (Danish). In the BMQ statements, discrepancies ranged from smaller inaccuracies toward completely different meaning. Some dissimilarities reflect different cultural beliefs about medicines.

CONCLUSION

When translating questionnaires, bilingual researchers should scrutinize translations across similar languages to address content validity across different countries and languages.

PRACTICE IMPLICATIONS

Our findings are of relevance to other BMQ translations in non-English countries, as direct comparisons between different translations might not be reliable or valid.

Risk factors for non-adherence to antidepressant treatment in patients with mood disorders

PURPOSE

Adherence to antidepressant therapy by patients with depressive disorders is essential not only to achieve a positive patient outcome but also to prevent a relapse. The aim of this study was to identify potential modelling factors influencing adherence to antidepressant treatment by patients with mood disorders in the community mental health care setting

METHODS

A total of 160 consecutive psychiatric outpatients attending two Community Mental Health Centres on Tenerife Island between September 2011 and May 2012 were asked to participate in the study; of these, 145 accepted. The Morisky self-report scale was used to assess adherence. The potential predictors examined included socio-demographic, clinical and therapeutic variables. The Clinical Global Impression-Severity and -Improvement scales and the Beck Depression Inventory were used for clinical assessment. Drug treatment side-effects were assessed using the "Self-report Antidepressant Side-Effect Checklist." All participants were also asked to complete the "Drug Attitude Inventory" (DAI), "Beliefs about Medicine Questionnaire" (BMQ), and "Leeds Attitude towards concordance Scale". Discriminant analyses were performed to predict non-adherence.

RESULTS

There was no clear correlation between adherence and the socio-demographic variables examined, but adherence was related to a positive attitude of the patients towards his/her treatment (DAI) and low scores in the BMQ-Harm and -Concern subscales. Non-adherence was also related to an increasing severity of depression and to the presence and severity of side-effects.

CONCLUSIONS

Among our study cohort, the profiles of adherent patients to antidepressant treatment were more closely associated with each patient's attitudes and beliefs than to objective socio-demographic variables. The severity of depression played a relevant role in adherence, but whether this role is direct or an interaction with several concurrent factors is not yet clear. Side-effects were also closely related to adherence, as conditioned by frequent polypharmacy.

Psychiatric outpatients' self-reported adherence versus psychiatrists' impressions on adherence in affective disorders

OBJECTIVE

The objective of this study is to explore correlation between patients' self-reported adherence to medication and their treating psychiatrists' impressions on adherence.

METHODS

During a 9-month period, 140 consecutive psychiatric outpatients with affective disorders attending two community mental health centers, and their treating psychiatrists, took part. Data were collected on socio-demographic, clinical, and therapeutic variables. The Clinical Global Impression-Severity and Improvement scales and the Beck Depression Inventory were used for clinical assessment. Adherence was assessed by the psychiatrist's report and the Morisky scale from patients. In addition, "Drug Attitude Inventory," "Beliefs about Medicine Questionnaire," and "Leeds Attitude towards concordance scale" were applied to all participants. A multivariate analysis of variance (Bonferroni control) and a subsequent stepwise regression were performed.

RESULTS

The allocation of patients to "adherent" or "non-adherent" categories by the patients themselves and their treating psychiatrists was divergent in more than 40% of the cases. The best agreement appears when treatment is prolonged. There is a better agreement with patients having a positive view of the medicines. When patients consider the medication harmful, this is when psychiatrists perceive more non-adherence. The agreement is also better in mild cases of depression.

CONCLUSIONS

Adherence was principally compromised by patient-related factors, especially their beliefs and attitudes toward their treatment and its duration.