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Babu V, Sylaja PN, Soman B, Varma RP, Ms M, Gl G, Kumar B S. A randomized controlled trial of medication adherence and management of risk factors for secondary prevention of stroke (MaMoRS) using a smartphone-based application. Int J Stroke 2024; 19:654-664. [PMID: 38533606 DOI: 10.1177/17474930241245612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
BACKGROUND There are little data on the use of smartphone-based applications for medication adherence and risk-factor control for the secondary prevention of stroke in low-and-middle-income countries (LMICs). AIMS The aim was to determine whether a smartphone-based app improved medication adherence, risk-factor control, and provided health education to stroke survivors for lifestyle and behavioral modifications. METHODS An unblinded, single-center randomized controlled double arm trial with 1:1 allocation among stroke survivors was performed in South India. The primary outcome was medication adherence, with co-primary outcomes of lifestyle and behavioral factors and control of vascular risk factors, at 3 and 6 months. RESULTS Among 351 stroke survivors screened, 209 were recruited. The mean (standard deviation (SD)) age of the intervention (n = 105) group was 60 (12) years and that of the control (n = 104) group was 60 (10) years. In the primary outcome, mean medication adherence significantly improved in the intervention group with a between group difference of 0.735 (95% confidence interval (CI) = 0.419 to 1.050), p < 0.001. Being in intervention group (OR = 4.5; 95% CI = 2.3 to 8.9), stroke recurrence (OR = 3.3 (95% CI = 1.9 to 7.8)), and regular physician visits (OR = 2.1; 95% CI = 1.0 to 4.4) were significant predictors of good medication adherence. Considering the co-primary outcomes, compared to the control group, participants in the intervention group had a greater improvement in self-reported healthy diet intake (p = 0.003), intake of fruits (p = 0.005), and were physically more active (p = 0.001). At 6 months, mean fasting blood sugar (p = 0.005) and high-density lipoprotein cholesterol higher (p = 0.024) in the intervention group. CONCLUSIONS The use of a mobile app is an effective method to improve medication adherence and risk-factor control in stroke survivors and is feasible in LMICs like India. DATA ACCESS STATEMENT Data used during the study are available from the corresponding author on request. TRIAL REGISTRATION The study is registered in Clinical Trial Registry of India (CTRI/2022/06/042980).
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Affiliation(s)
- Veena Babu
- Neurology Department, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, India
| | - P N Sylaja
- Neurology Department, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, India
| | - Biju Soman
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, India
| | - Ravi Prasad Varma
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, India
| | - Manju Ms
- Neurology Department, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, India
| | - Geethu Gl
- Neurology Department, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, India
| | - Suresh Kumar B
- Neurology Department, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, India
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Siddiqui F, Hewitt C, Jennings H, Coales K, Mazhar L, Boeckmann M, Siddiqi N. Self-management of chronic, non-communicable diseases in South Asian settings: A systematic mixed-studies review. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0001668. [PMID: 38190368 PMCID: PMC10773968 DOI: 10.1371/journal.pgph.0001668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 11/14/2023] [Indexed: 01/10/2024]
Abstract
Self-management is crucial in mitigating the impacts of a growing non-communicable disease (NCD) burden, particularly in Low and Middle-Income countries. What influences self-management in these settings, however, is poorly understood. We aimed to identify the determinants of self-management in the high NCD region of South Asia and explore how they influence self-management. A systematic mixed-studies review was conducted. Key electronic databases [MEDLINE (1946+), Embase (1974+), PsycInfo (1967+) and CINAHL (EBSCOhost)] in March 2022 (and updated in April 2023) were searched for studies on the self-management of four high-burden NCD groups: cardiovascular diseases, type 2 diabetes, chronic respiratory diseases and depression. Study characteristics and quantitative data were extracted using a structured template, and qualitative information was extracted using NVivo. Quality appraisal was done using the Mixed Methods Assessment Tool (MMAT). Quantitative findings were organised using the Commission on Social Determinants of Health (CSDH) framework and synthesised narratively, supported by effect direction plots. Qualitative findings were thematically synthesised. Both were integrated in a mixed synthesis. Forty-four studies (26 quantitative, 16 qualitative and 2 mixed-methods studies) were included, the majority of which were conducted in urban settings and among individuals with diabetes and cardiovascular diseases. Higher age, education, and income (structural determinants), health-related knowledge, social support and self-efficacy (psychosocial determinants), longer illness duration and physical comorbidity (biologic determinants), and the affordability of medicine (health-system determinants) were key determinants of self-management. Qualitative themes highlighted the role of financial adversity and the social and physical environment in shaping self-management.A complex interplay of structural and intermediary social determinants shapes self-management in South Asian settings. Multi-component, whole-systems approaches could boost self-management in these settings. Key areas include empowerment and education of patients and wider community, design and delivery of bespoke behavioural interventions and a stronger emphasis on supporting self-management in healthcare settings.
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Affiliation(s)
- Faraz Siddiqui
- Department of Health Sciences, Mental Health and Addictions Research Group, University of York, York, United Kingdom
| | - Catherine Hewitt
- Department of Health Sciences, Mental Health and Addictions Research Group, University of York, York, United Kingdom
- Department of Health Sciences, York Trials Unit, University of York, York, United Kingdom
| | - Hannah Jennings
- Department of Health Sciences, Mental Health and Addictions Research Group, University of York, York, United Kingdom
- Hull York Medical School, York, United Kingdom
| | - Karen Coales
- Department of Health Sciences, Mental Health and Addictions Research Group, University of York, York, United Kingdom
| | - Laraib Mazhar
- Penn State University College of Medicine, Hershey, Pennsylvania, United States of America
| | - Melanie Boeckmann
- Department of Global Health, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany
| | - Najma Siddiqi
- Department of Health Sciences, Mental Health and Addictions Research Group, University of York, York, United Kingdom
- Hull York Medical School, York, United Kingdom
- Bradford District Care NHS foundation trust, Bradford, United Kingdom
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Cao W, Wang J, Wang Y, Hassan II, Kadir AA. mHealth App to improve medication adherence among older adult stroke survivors: Development and usability study. Digit Health 2024; 10:20552076241236291. [PMID: 38465293 PMCID: PMC10921861 DOI: 10.1177/20552076241236291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 02/14/2024] [Indexed: 03/12/2024] Open
Abstract
Background Effective medication adherence is vital for older adult stroke survivors, yet 20-33% cease treatment within a year post-discharge, increasing risks of recurrent strokes and mortality. A mobile health (mHealth) app could be a novel tool to improve medication adherence among stroke survivors because of its potential to increase patient empowerment. A few stroke-related apps provide information and support to stroke survivors. However, none have focused on medication adherence and documented their development and evaluation process, particularly those focused on this older population. Objective This study aims to design and develop a smartphone app called OASapp to improve medication adherence among older adult stroke survivors and evaluate its usability. Methods OASapp was developed in a three-phase development process. Phase 1 is the exploration phase (including a cross-sectional survey, a systematic review, a search for stroke apps on the app stores of Apple App Store and Google Play Store, and a nominal group technique). In phase 2, a prototype was designed based on the Health Belief Model and Technology Acceptance Model. In phase 3, Alpha and Beta testing was conducted to validate the app. Results Twenty-five features for inclusion in the app were collected in round one, and 14 features remained and were ranked by the participants during nominal group technique. OASapp included five core components (medication management, risk factor management, health information, communication, and stroke map). Users of OASapp were satisfied based on reports from Alpha and Beta testing. The mean Usability Metric for User Experience (UMUX) score was 71.4 points (SD 14.6 points). Conclusion OASapp was successfully developed using comprehensive, robust, and theory-based methods and was found to be highly accepted by users. Further research is needed to establish the clinical efficacy of the app so that it can be utilized to improve clinically relevant outcomes.
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Affiliation(s)
- Wenjing Cao
- Xiangnan University, Chenzhou, Hunan Province, China
- School of Health Sciences, Universiti Sains Malaysia, Kota Baru, Kelantan, Malaysia
| | - Juan Wang
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, China
| | - Yuhui Wang
- Central South University, Changsha, Hunan Province, China
| | - Intan Idiana Hassan
- School of Health Sciences, Universiti Sains Malaysia, Kota Baru, Kelantan, Malaysia
| | - Azidah Abdul Kadir
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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Zhou T, de Havenon A, Sheth KN, Ross JS. Disability Status and Secondary Prevention Among Survivors of Stroke: A Cross-Sectional Analysis of the 2011 to 2018 National Health and Nutrition Examination Survey. J Am Heart Assoc 2023; 12:e030869. [PMID: 38014672 PMCID: PMC10727323 DOI: 10.1161/jaha.123.030869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 11/01/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Among survivors of stroke, adherence to secondary prevention care is associated with decreased risk of recurrent stroke. However, not all survivors of stroke use secondary stroke prevention treatment. We examined the association between the disability status of survivors of stroke and their treatment and control of diabetes, hyperlipidemia, and hypertension. METHODS AND RESULTS In a cross-sectional analysis of the 2011 to 2018 National Health and Nutrition Examination Survey, we compared diabetes, hyperlipidemia, and hypertension treatment and control rates among self-reported survivors of stroke age ≥20 years with and without disability. Disability was defined as self-reporting any of 5 physical or 4 functional domains assessed using a structured questionnaire. Logistic regression models adjusted for age, sex, race and ethnicity, and history of medical conditions were used to estimate associations between disability status and risk factor treatment and control. The mean age of survivors of stroke was 65.1 years, and 55.5% were female; 76% (95% CI, 72.7%-79.3%) self-reported at least 1 disability. Age-standardized treatment rates for diabetes, hyperlipidemia, and hypertension were 33.1% (95% CI, 26.9%-39.2%), 67.5% (95% CI, 62.6%-72.3%), and 78.4% (95% CI, 74.6%-82.2%), respectively. Age-standardized control rates for diabetes, hyperlipidemia, and hypertension were 86.8% (95% CI, 83.8%-89.8%), 20.5% (95% CI, 15.0%-25.9%), and 47.1% (95% CI, 42.6%-51.7%), respectively. In adjusted models, those with and without disabilities had similar odds of risk factor treatment and control. CONCLUSIONS In the United States, three-quarters of survivors of stroke self-reported a disability, and these patients had similar odds of diabetes, hyperlipidemia, and hypertension treatment and control compared with those without disability.
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Affiliation(s)
| | - Adam de Havenon
- Department of Neurology, Yale Center for Brain and Mind HealthYale School of MedicineNew HavenCTUSA
| | - Kevin N. Sheth
- Department of Neurology, Yale Center for Brain and Mind HealthYale School of MedicineNew HavenCTUSA
- Division of Neurocritical Care and Emergency NeurologyDepartments of Neurology and Neurosurgery, Yale School of MedicineNew HavenCTUSA
| | - Joseph S. Ross
- Section of General Internal Medicine and National Clinician Scholars Program, Department of Internal MedicineYale School of MedicineNew HavenCTUSA
- Department of Health Policy and ManagementYale School of Public HealthNew HavenCTUSA
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Marques MD, Pedrosa RBDS, Oliveira HC, Gallani MCBJ, Rodrigues RCM. Validity, sensitivity and specificity of a measure of medication adherence instrument among patients taking oral anticoagulants. Pharmacol Res Perspect 2023; 11:e01113. [PMID: 37897150 PMCID: PMC10611946 DOI: 10.1002/prp2.1113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 10/29/2023] Open
Abstract
Although self-report instruments are currently considered a valuable tool for measuring adherence, due to their low cost and ease of implementation, there are still important factors that impact measurement accuracy, such as social desirability and memory bias. Thus, the Global Assessment of Medication Adherence Instrument (GEMA) was developed to provide an accurate measure of this construct. The aim of this study was to evaluate the properties of the measurement of the Global Evaluation of Medication Adherence Instrument (GEMA) among patients with chronic diseases. A methodological study was conducted in the public hospital of the state of São Paulo, Brazil. The adherence to anticoagulants as well as the international normalized ratio (INR) was assessed on 127 patients. Besides GEMA, two other instruments were used to assess adherence: the Morisky Medication Adherence Scale-8 (MMAS-8) and the Measurement of Adhesion to Treatments (MAT). The GEMA presented a satisfactory level of specificity (0.76) to identify adherents among those with a stable INR, low sensitivity (0.43) for the identification of non-adherents among those with an unstable INR, and a Positive Predictive Value of 0.70. Positive and weak to moderate correlations were observed between the proportion of doses assessed with GEMA and the scores on the MMAS-8 (r = .26 and r = .22, respectively) and the MAT (r = .22 and r = .30, respectively). The GEMA presented good practicality, acceptability, and evidence of specificity regarding the stability of the INR. The validity of the construct was partially supported by the relationship with self-reported measures of adherence.
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Tolley A, Grewal K, Weiler A, Papameletiou AM, Hassan R, Basu S. Factors influencing adherence to non-communicable disease medication in India: secondary analysis of cross-sectional data from WHO - SAGE2. Front Pharmacol 2023; 14:1183818. [PMID: 37900158 PMCID: PMC10603298 DOI: 10.3389/fphar.2023.1183818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 09/28/2023] [Indexed: 10/31/2023] Open
Abstract
Background: Non-communicable diseases (NCDs) are a leading cause of death globally and disproportionately affect those in low- and middle-income countries lower-middle-income countries. Poor medication adherence among patients with NCDs is prevalent in India due to lack of initiation, missed dosing or cessation of treatment, and represents a growing healthcare and financial burden. Objective: This study aimed to identify factors influencing medication adherence in adults with NCDs in India. Methods: We performed a cross-sectional study, conducting secondary data analysis on the second wave of the World Health Organisation's 'Study on global AGEing and adult health (SAGE)', a survey that collected data from predominantly older adults across India. Bivariate analysis and multivariate logistic regression modelling were conducted to specifically interrogate the reasons for lack of initiation and cessation of treatment. Reporting of this study was informed by the STROBE guidelines. Results: The average medication adherence rate was 51% across 2,840 patients with one or more NCDs, reflecting non-initiation and lack of persistence of treatment. The strongest factor significantly predicting non-adherence to medication across these components was multimorbidity (odds ratio 0.47, 95% CI 0.40-0.56). Tobacco use (OR = 0.76, CI 0.59-0.98) and never having attended school (OR = 0.75, CI 0.62-0.92) were significantly associated with poor medication adherence (p < 0.05) while rural living (OR = 0.70, CI 0.48-1.02), feelings of anxiety (OR = 0.84, CI 0.66-1.08) and feelings of depression (OR = 0.90, CI 0.70-1.16) were factors lacking statistically significant association with medication adherence on multivariate analysis. Older age (OR = 2.02, CI 1.51-2.71) was significantly associated with improved medication adherence whilst there was a weak association between increased wealth and improved medication use. Limitations: The SAGE2 survey did not capture whether patients were taking their medication doses according to prescribed instructions-as a result our findings may under-estimate the true prevalence of medication non-adherence. Conclusion: Our analysis provides evidence that poor medication adherence in India is multifactorial, with distinct socioeconomic and health-system factors interacting to influence patient decision making. Future large-scale surveys interrogating adherence should assess all components of adherence specifically, whilst public health interventions to improve medication adherence should focus on barriers that may exist due to multimorbidity, comorbid depression and anxiety, and low educational status.
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Affiliation(s)
- Abraham Tolley
- School of Clinical Medicine, University of Cambridge, Cambridge, England
| | - Kirpal Grewal
- Faculty of Natural Science, University of Cambridge, Cambridge, England
| | - Alessa Weiler
- Faculty of Natural Science, University of Cambridge, Cambridge, England
| | | | - Refaat Hassan
- School of Clinical Medicine, University of Cambridge, Cambridge, England
| | - Saurav Basu
- Indian Institute of Public Health, Public Health Foundation of India, New Delhi, India
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Ruksakulpiwat S, Benjasirisan C, Ding K, Phianhasin L, Thorngthip S, Ajibade AD, Thampakkul J, Zhang AY, Voss JG. Utilizing Social Determinants of Health Model to Understand Barriers to Medication Adherence in Patients with Ischemic Stroke: A Systematic Review. Patient Prefer Adherence 2023; 17:2161-2174. [PMID: 37667687 PMCID: PMC10475305 DOI: 10.2147/ppa.s420059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/11/2023] [Indexed: 09/06/2023] Open
Abstract
Introduction Ischemic strokes and their recurrence create an immense disease burden globally. Therefore, preventing recurrent strokes by promoting medication adherence is crucial to reduce morbidity and mortality. In addition, understanding the barriers to medication adherence related to the social determinants of health (SDoH) could promote equity among persons with ischemic stroke. Objective To explore the barriers to medication adherence among patients with ischemic stroke through the SDoH. Methods This systematic review included studies published between January 2018 and December 2022 identified through PubMed, MEDLINE, Web of Science, and CINAHL Plus Full Text. The descriptions of the studies were systematically summarized and discussed based on the SDoH from the US Healthy People 2030 initiative. Results Eight studies met the inclusion criteria and were included in this review. The most common barrier to adherence was inappropriate medication beliefs, medication side effects, and patient-physician relationship, which relate to the dimensions of healthcare access and quality. Health literacy and health perception, dependent on education access and quality, frequently influenced adherence. Other social determinants, such as financial strain and social and community context, were found to alter adherence behaviors. No study addressed the neighborhood and built environment domain. We found that cognitive impairment is another factor that impacts adherence outcomes among stroke patients. Conclusion Multifaceted approaches are needed to address the SDoH to improve medication adherence among patients with ischemic stroke. This review emphasized strategies, including patient education, provider-patient communication, social support, health literacy, technology, and policy advocacy to enhance adherence.
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Affiliation(s)
- Suebsarn Ruksakulpiwat
- Department of Medical Nursing, Faculty of Nursing, Mahidol University, Bangkok, Thailand
| | | | - Kedong Ding
- Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Lalipat Phianhasin
- Department of Medical Nursing, Faculty of Nursing, Mahidol University, Bangkok, Thailand
| | - Sutthinee Thorngthip
- Department of Nursing Siriraj Hospital, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anuoluwapo D Ajibade
- College of Art and Science, Department of Anthropology, Case Western Reserve University, Cleveland, OH, USA
| | - Jai Thampakkul
- Case School of Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Amy Y Zhang
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Joachim G Voss
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
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Tolley A, Hassan R, Sanghera R, Grewal K, Kong R, Sodhi B, Basu S. Interventions to promote medication adherence for chronic diseases in India: a systematic review. Front Public Health 2023; 11:1194919. [PMID: 37397765 PMCID: PMC10311913 DOI: 10.3389/fpubh.2023.1194919] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/02/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction Cost-effective interventions that improve medication adherence are urgently needed to address the epidemic of non-communicable diseases (NCDs) in India. However, in low- and middle-income countries like India, there is a lack of analysis evaluating the effectiveness of adherence improving strategies. We conducted the first systematic review evaluating interventions aimed at improving medication adherence for chronic diseases in India. Methods A systematic search on MEDLINE, Web of Science, Scopus, and Google Scholar was conducted. Based on a PRISMA-compliant, pre-defined methodology, randomized control trials were included which: involved subjects with NCDs; were located in India; used any intervention with the aim of improving medication adherence; and measured adherence as a primary or secondary outcome. Results The search strategy yielded 1,552 unique articles of which 22 met inclusion criteria. Interventions assessed by these studies included education-based interventions (n = 12), combinations of education-based interventions with regular follow up (n = 4), and technology-based interventions (n = 2). Non-communicable diseases evaluated commonly were respiratory disease (n = 3), type 2 diabetes (n = 6), cardiovascular disease (n = 8) and depression (n = 2). Conclusions Although the vast majority of primary studies supporting the conclusions were of mixed methodological quality, patient education by CHWs and pharmacists represent promising interventions to improve medication adherence, with further benefits from regular follow-up. There is need for systematic evaluation of these interventions with high quality RCTs and their implementation as part of wider health policy. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022345636, identifier: CRD42022345636.
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Affiliation(s)
| | | | | | | | - Ruige Kong
- University of Cambridge, Cambridge, United Kingdom
| | - Baani Sodhi
- Indian Institute of Public Health-Delhi, Gurugram, India
| | - Saurav Basu
- Indian Institute of Public Health-Delhi, Gurugram, India
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