The impact of depressive symptoms and psychosocial factors on medication adherence in cardiovascular disease

Using the Multidimensional Health Locus of Control Scale Form C to Investigate Health Beliefs About Bladder Cancer Prevention and Treatment Among Male Patients: Cross-Sectional Study

BACKGROUND

Bladder cancer is a leading cause of death among Chinese male populations in recent years. The health locus of control construct can mediate health status and outcomes, and it has proven helpful in predicting and explaining specific health-related behaviors. However, it has never been used to investigate health beliefs about bladder cancer prevention and treatment.

OBJECTIVE

This study aimed to classify male patients into different latent groups according to their beliefs about bladder cancer prevention and treatment and to identify associated factors to provide implications for the delivery of tailored education and interventions and the administration of targeted prevention and treatment.

METHODS

First, we designed a four-section questionnaire to solicit data: section 1-age, gender, and education; section 2-the communicative subscale of the All Aspects of Health Literacy Scale; section 3-the eHealth Literacy Scale; and section 4-health beliefs about bladder cancer prevention and treatment measured by the Multidimensional Health Locus of Control Scale Form C. We hypothesized that the participants' health beliefs about bladder cancer prevention and treatment measured in section 4 could be closely associated with information collected through sections 1 to 3. We recruited 718 Chinese male patients from Qilu Hospital of Shandong University, China, and invited them to participate in a web-based questionnaire survey. Finally, we used latent class analysis to identify subgroups of men based on their categorical responses to the items on the Multidimensional Health Locus of Control Scale Form C and ascertained factors contributing to the low self-efficacy group identified.

RESULTS

We identified 2 subgroups defined as low and moderate self-efficacy groups representing 75.8% (544/718) and 24.2% (174/718) of the total sample, respectively. Men in the low self-efficacy cluster (cluster 1: 544/718, 75.8%) were less likely to believe in their own capability or doctors' advice to achieve optimal outcomes in bladder cancer prevention and treatment. Men in the moderate self-efficacy cluster (cluster 2: 174/718, 24.2%) had distinct psychological traits. They had stronger beliefs in their own capability to manage their health with regard to bladder cancer prevention and treatment and moderate to high levels of trust in health and medical professionals and their advice to achieve better prevention and treatment outcomes. Four factors contributing to low self-efficacy were identified, including limited education (Year 6 to Year 12), aged ≥44 years, limited communicative health literacy, and limited digital health literacy.

CONCLUSIONS

This was the first study investigating beliefs about bladder cancer prevention and treatment among Chinese male patients. Given that bladder cancer represents a leading cause of death among Chinese male populations in recent years, the low self-efficacy cluster and associated contributing factors identified in this study can provide implications for clinical practice, health education, medical research, and health policy-making.

Functional Health Literacy Among Chinese Populations and Associated Factors: Latent Class Analysis

BACKGROUND

Poor functional health literacy has been found to be independently associated with poor self-assessed health, poor understanding of one's health condition and its management, and higher use of health services. Given the importance of functional health literacy, it is necessary to assess the overall status of functional health literacy in the general public. However, the literature review shows that no studies of functional health literacy have been conducted among the Chinese population in China.

OBJECTIVE

This study aimed to classify Chinese populations into different functional health literacy clusters and ascertain significant factors closely associated with low functional health literacy to provide some implications for health education, medical research, and public health policy making.

METHODS

We hypothesized that the participants' functional health literacy levels were associated with various demographic characteristics. Therefore, we designed a four-section questionnaire including the following information: (1) age, gender, and education; (2) self-assessed disease knowledge; (3) 3 validated health literacy assessment tools (ie, the All Aspects of Health Literacy Scale, the eHealth Literacy Scale, and the 6-item General Health Numeracy Test); and (4) health beliefs and self-confidence measured by the Multidimensional Health Locus of Control Scales Form B. Using randomized sampling, we recruited survey participants from Qilu Hospital affiliated to Shandong University, China. The questionnaire was administered via wenjuanxing. A returned questionnaire was valid only when all question items included were answered, according to our predefined validation criterion. All valid data were coded according to the predefined coding schemes of Likert scales with different point (score) ranges. Finally, we used latent class analysis to classify Chinese populations into clusters of different functional health literacy and identify significant factors closely associated with low functional health literacy.

RESULTS

All data in the 800 returned questionnaires proved valid according to the predefined validation criterion. Applying latent class analysis, we classified Chinese populations into low (n=292, 36.5%), moderate-to-adequate (n=286, 35.7%), and low-to-moderate (n=222, 27.8%) functional health literacy groups and identified five factors associated with low communicative health literacy: (1) male gender (aged 40-49 years), (2) lower educational attainment (below diploma), (3) age between 38 and 68 years, (4) lower self-efficacy, and (5) belief that staying healthy was a matter of luck.

CONCLUSIONS

We classified Chinese populations into 3 functional health literacy groups and identified 5 factors associated with low functional health literacy. These associated factors can provide some implications for health education, medical research, and health policy making.

Susceptibility to Breast Cancer Misinformation Among Chinese Patients: Cross-sectional Study

BACKGROUND

Currently, breast cancer is the most commonly diagnosed cancer and the sixth-leading cause of cancer-related deaths among Chinese women. Worse still, misinformation contributes to the aggravation of the breast cancer burden in China. There is a pressing need to investigate the susceptibility to breast cancer misinformation among Chinese patients. However, no study has been performed in this respect.

OBJECTIVE

This study aims to ascertain whether some demographics (age, gender, and education), some health literacy skills, and the internal locus of control are significantly associated with the susceptibility to misinformation about all types of breast cancers among randomly sampled Chinese patients of both genders in order to provide insightful implications for clinical practice, health education, medical research, and health policy making.

METHODS

We first designed a questionnaire comprising 4 sections of information: age, gender, and education (section 1); self-assessed disease knowledge (section 2); the All Aspects of Health Literacy Scale (AAHLS), the eHealth Literacy Scale (eHEALS), the 6-item General Health Numeracy Test (GHNT-6), and the "Internal" subscale of the Multidimensional Health Locus of Control (MHLC) scales (section 3); and 10 breast cancer myths collected from some officially registered and authenticated websites (section 4). Subsequently, we recruited patients from Qilu Hospital of Shandong University, China, using randomized sampling. The questionnaire was administered via wenjuanxing, the most popular online survey platform in China. The collected data were manipulated in a Microsoft Excel file. We manually checked the validity of each questionnaire using the predefined validity criterion. After that, we coded all valid questionnaires according to the predefined coding scheme, based on Likert scales of different point (score) ranges for different sections of the questionnaire. In the subsequent step, we calculated the sums of the subsections of the AAHLS and the sums of the 2 health literacy scales (the eHEALS and GHNT-6) and the 10 breast cancer myths. Finally, we applied logistic regression modeling to relate the scores in section 4 to the scores in sections 1-3 of the questionnaire to identify what significantly contributes to the susceptibility to breast cancer misinformation among Chinese patients.

RESULTS

All 447 questionnaires collected were valid according to the validity criterion. The participants were aged 38.29 (SD 11.52) years on average. The mean score for their education was 3.68 (SD 1.46), implying that their average educational attainment was between year 12 and a diploma (junior college). Of the 447 participants, 348 (77.85%) were women. The mean score for their self-assessed disease knowledge was 2.50 (SD 0.92), indicating that their self-assessed disease knowledge status was between "knowing a lot" and "knowing some." The mean scores of the subconstructs in the AAHLS were 6.22 (SD 1.34) for functional health literacy, 5.22 (SD 1.54) for communicative health literacy, and 11.19 (SD 1.99) for critical health literacy. The mean score for eHealth literacy was 24.21 (SD 5.49). The mean score for the 6 questions in the GHNT-6 was 1.57 (SD 0.49), 1.21 (SD 0.41), 1.24 (SD 0.43), 1.90 (SD 0.30), 1.82 (SD 0.39), and 1.73 (SD 0.44), respectively. The mean score for the patients' health beliefs and self-confidence was 21.19 (SD 5.63). The mean score for their response to each myth ranged from 1.24 (SD 0.43) to 1.67 (SD 0.47), and the mean score for responses to the 10 myths was 14.03 (SD 1.78). Through interpreting these descriptive statistics, we found that Chinese female patients' limited ability to rebut breast cancer misinformation is mainly attributed to 5 factors: (1) lower communicative health literacy, (2) certainty about self-assessed eHealth literacy skills, (3) lower general health numeracy, (4) positive self-assessment of general disease knowledge, and (5) more negative health beliefs and lower levels of self-confidence.

CONCLUSIONS

Drawing on logistic regression modeling, we studied the susceptibility to breast cancer misinformation among Chinese patients. The predicting factors of the susceptibility to breast cancer misinformation identified in this study can provide insightful implications for clinical practice, health education, medical research, and health policy making.

The association of depression with mortality and major adverse limb event outcomes in patients with peripheral artery disease: A systematic review and meta-analysis

BACKGROUND

Peripheral artery disease (PAD) is highly prevalent and associated with poor outcomes. Depression is a risk factor for adverse outcomes in patients with coronary artery disease. Despite evidence showing that depression is common in patients with PAD, less is known about its association with adverse prognostic outcomes. To address this, we conducted a systematic review and meta-analysis to summarize the association between depression and outcomes in patients with PAD.

METHODS

We performed a systematic search of eight databases to January 2022 including studies that reported a risk estimate for the association of depression or depressive symptoms with all-cause mortality or major adverse limb events (MALE) in patients with PAD and pooled results in a meta-analysis. Risk of bias was assessed using ROBINS-I.

RESULTS

Of the 7048 articles screened, 5 observational studies with 119,123 patients were included. A total of 16.2 % had depression or depressive symptoms. Depression was associated with a statistically significant increased risk of all-cause mortality (HR 1.24, confidence interval 1.07-1.25, p = .005). The association between depression and MALE was not significant but trended toward a positive association.

LIMITATIONS

Due to lack of data, results were limited by a single study with a large sample size, overrepresentation of men, and lack of information of depression severity or treatment status.

CONCLUSION

Depression or depressive symptoms are associated with a 24 % increased risk of all-cause mortality in patients with PAD. Future work should explore the mechanisms and directionality of this association and identify depression as an important comorbidity to address for patients with PAD.

REGISTRATION

PROSPERO CRD 42021223694.

Associations Between Personality Functioning, Childhood Trauma and Non-adherence in Cardiovascular Disease: A Psychodynamically-Informed Cross-Sectional Study

Objective

Although treatment adherence and lifestyle changes significantly improve the prognosis of cardiovascular disease, many patients do not comply with clinician recommendations. Personality functioning appears to be of importance and is hypothesized to be superior to symptom-based measures in explaining individual differences in non-adherence.

Methods

194 cardiology inpatients (mean age = 70.6 years, 60% male) were assessed using self-report measures in a cross-sectional design. Patients were assessed using the short version of the Operationalized Psychodynamic Diagnosis Structure Questionnaire (OPD-SQS) to measure personality functioning, as well as the Childhood Trauma Screener (CTS), the Patient Health Questionnaire (PHQ-9) for symptoms of depression, and the Generalized Anxiety Disorder Scale-7 (GAD-7). To assess non-adherence we introduced a brief, novel scale.

Results

Non-adherence correlated significant with personality functioning (r = 0.325), childhood trauma (r = 0.204) and depressiveness (r = 0.225). In a stepwise multiple regression analysis with socio-demographic variables inputted into the model, higher deficits in personality functioning, higher levels of childhood trauma, and male gender were associated with non-adherence (adjusted R2 = 0.149, F(3,190) = 12.225, p < 0.01). Level of depressive symptoms, anxiety, age, education, and income showed no significant additional predictive value and were excluded from the model.

Conclusion

In cardiovascular disease, personality functioning, childhood trauma and male gender are associated with non-adherence and appear to be more important than symptom reports of depression and anxiety. This highlights the relevance of basic impairments in intra- and interpersonal functioning in chronic disease, where the patient’s adherence is central.

Heart and brain interactions : Pathophysiology and management of cardio-psycho-neurological disorders

Cardiovascular diseases (CVD) and mental health disorders (MHD; e.g. depression, anxiety and cognitive dysfunction) are highly prevalent and are associated with significant morbidity and mortality and impaired quality of life. Currently, possible interactions between pathophysiological mechanisms in MHD and CVD are rarely considered during the diagnostic work-up, prognostic assessment and treatment planning in patients with CVD, and research addressing bidirectional disease mechanisms in a systematic fashion is scarce. Besides some overarching pathogenetic principles shared by CVD and MHD, there are specific syndromes in which pre-existing neurological or psychiatric illness predisposes and contributes to CVD development (as in Takotsubo syndrome), or in which the distorted interplay between innate immune and central nervous systems and/or pre-existing CVD leads to secondary MHD and brain damage (as in peripartum cardiomyopathy or atrial fibrillation). Clinical manifestations and phenotypes of cardio-psycho-neurological diseases depend on the individual somatic, psychosocial, and genetic risk profile as well as on personal resilience, and differ in many respects between men and women. In this article, we provide arguments on why, in such conditions, multidisciplinary collaborations should be established to allow for more comprehensive understanding of the pathophysiology as well as appropriate and targeted diagnosis and treatment. In addition, we summarize current knowledge on the complex interactions between the cardiovascular and central nervous systems in Takotsubo syndrome and peripartum cardiomyopathy, and on the neurological and psychiatric complications of atrial fibrillation.

The Association between Medication Experiences and Beliefs and Low Medication Adherence in Patients with Chronic Disease from Two Different Societies: The USA and the Sultanate of Oman

This cross-sectional study aimed to describe the association between medication experiences and beliefs and self-reported medication adherence in patients with chronic diseases in two different samples from two different societies: the USA and the Sultanate of Oman. The Morisky Medication Adherence Score (MMAS-8) questionnaire was used to measure medication adherence. Three items (statements) were used for measuring medication experiences and beliefs variable on a four-point Likert scale adapted from the 2015 National Consumer Survey of the Medication Experience and Pharmacists’ Role (NCSME&PR). In the U.S., quantitative secondary data analysis of 13,731 participants was conducted using the 2015 NCSME&PR, a self-administered online survey coordinated by Qualtrics Panels between 28 April 2015 and 22 June 2015. The same variables were translated into Arabic, with studies conducted at the Royal Court Medical Center in Oman, and data from 714 participants were collected between 16 June 2019 and 16 August 2019. Data were analyzed using IMB/SPSS version 24.0 software. Chi-square analysis and descriptive statistics were used. The results showed that the low adherence rates for medication (MMAS-8 < 6) were 56% and 52% in Omani and U.S. groups, respectively. Approximately 90% of the U.S. and Omani participants believed that “medicines are a life-saver”; however, medication adherence was higher in Oman (30%) than in the United States (9%) for these participants. In total, 60% of the U.S. and 29% of Omani participants believed that “medicines are a burden”; however, about 60–65% of participants in both countries were in the low medication adherence group. Additionally, 63% of the U.S. and 83% of the Omani participants disagreed that “medicines do more harm than good”; however, medication adherence in the U.S. (15%) was higher than in Oman (8%). In conclusion, a decrease in low medication adherence was observed with positive medication experiences and beliefs. However, the impacts of medication experiences and beliefs on low medication adherence rates were different from one population to another. The “medication burden” statement resulted in the highest percentage of difference in terms of low medication adherence rates between those who agree and those who disagree in the U.S. group (20%), whereas the “medicines are a life-saver” statement resulted in a greater difference in the Omani group (30%). Proper communication between patients and healthcare providers based on the patient’s medication experiences and beliefs will substantially improve medication adherence.

Health Control Beliefs and Attitude Toward Treatment in Psychiatric and Non-Psychiatric Clinical Samples

Although there is accumulating evidence on the potential influencing factors of medication adherence, the knowledge about patients' attitudes and beliefs toward treatment is only partly utilized in adherence-improving strategies. Several internal and external factors determining adherence have been described regarding many chronic somatic diseases but in recent research, insight on psychiatric patients has been exclusively lacking. As a result, there is a scarcity of effective adherence-improving interventions. Identification of any specific differences or similarities between the attitudes toward treatment of psychiatric and non-psychiatric patients would help to support adherent behavior. We recruited 189 participants from four departments of general psychiatry (GEN PSYCH, n = 106), addictology (ADDICT, n = 42) and somatic diseases (NON PSYCH, n = 41). The Patient's Health Belief Questionnaire on Psychiatric Treatment (PHBQPT) was performed to assess the patients' attitude toward drug treatment, perceived health locus of control, and psychological reactance. The most robust difference of the PHBQT scores occurred between the GEN PSYCH and ADDICT subgroups. ADDICT patients scored significantly higher on the internal and external health locus of control and on the Psychological Reactance subscale as well. While GEN PSYCH subjects provided higher scores on the Positive Aspect of Medication compared to ADDICT persons. Interestingly, the only difference between the GEN PSYCH and NON-PSYCH groups was the more pronounced mistrust in physicians in the case of psychiatric patients. Our data suggest that mistrust toward medication does not differ in psychiatric and non-psychiatric samples, while the acceptance of the doctor's competency may be stronger in the non-psychiatric sample. The analysis of these factors provides information which could help us better understand this important issue and to develop more efficient interventions for improving adherence.

Development of the InCharge Health Mobile App to Improve Adherence to Hydroxyurea in Patients With Sickle Cell Disease: User-Centered Design Approach

Background

Sickle cell disease (SCD) is an inherited blood disorder causing acute complications and chronic progressive end organ damage. SCD is associated with significant morbidity, early mortality, impaired health-related quality of life, and increased acute health care utilization. Hydroxyurea is a US Food and Drug Administration–approved medication that reduces disease complications, acute health care utilization, and costs. However, adherence to hydroxyurea is suboptimal. Mobile health (mHealth) interventions have the potential to improve hydroxyurea adherence, but few examples exist that are specific to the SCD population.

Objective

This study aimed to design a mHealth intervention for individuals with SCD to improve adherence to hydroxyurea, using a user-centered design that was informed by specific barriers to hydroxyurea adherence and utilization in this population.

Methods

This study consisted of 4 phases. In phase 1, individuals with SCD and health care providers participated in an optimization digital workshop. In phase 2, patients completed surveys pertaining to their interest in mHealth use, barriers and facilitators to hydroxyurea use, and health literacy. Phases 3 and 4 involved semistructured interviews and focus groups, respectively, and used the Health Belief Model (HBM) as the framework to investigate drivers of poor hydroxyurea adherence and to inform the development of an app prototype. In addition, in phase 4, we have incorporated the patients’ feedback on the preliminary app prototype and its features.

Results

Barriers to hydroxyurea adherence were consistent with the literature and included forgetfulness and several specific thoughts and emotions associated with hydroxyurea use (eg, fear of side effects, depression, stigma, and hopelessness). In addition, more than half of the participants reported potentially low health literacy. Preferred patient app features included 7 key components, namely (1) medication reminders and tracker, (2) disease education, (3) communication, (4) personalization, (5) motivation, (6) support during pain episodes, and (7) social support. Utilizing a user-centered design approach, data obtained from patients and providers were translated into features within the app, mapping to components of the HBM and the specific drivers of hydroxyurea adherence and matching the literacy level of the population, resulting in the development of a novel mobile app called InCharge Health.

Conclusions

The InCharge Health app is an mHealth intervention developed with substantial input from users and by mapping the HBM as the framework that guided the choice for its components. InCharge Health is a customized product for the SCD population aimed at optimizing medication adherence, with the end goal of improving quality of life and health outcomes among patients with SCD. The efficacy and implementation of the InCharge Health app as an mHealth intervention to promote hydroxyurea adherence will be tested in a future stepped-wedge multicenter trial for adolescents and adults with SCD.

Depression and medication-adherence in patients with hypertension attending a tertiary health facility in South-West Nigeria

Introduction

In Nigeria, approximately 4.33 million adults suffer from hypertension and about a third of them do not adhere to prescribed medications. Depression has been reported to significantly predict poor medication adherence. The relationship between medication non-adherence and co-morbid depressive disorder in patients with hypertension has not been adequately explored in this environment. The study aimed to determine the prevalence of depression in patients with hypertension. The association between socio-demographic characteristics and presence of co-morbidity on medication adherence was also determined.

Methods

A cross-sectional descriptive research design was adopted for the study. A socio-demographic questionnaire, the modified Morisky Medication Adherence Scale (MMAS), the Hamilton Rating Scale for Depression (HAM-D) and the Mini International Neuropsychiatric Interview (MINI), were administered to four hundred patients with hypertension attending medical out-patient clinic between August and September 2012.

Results

About 43% (168) were aged 61 to 64 years the majority being females, with a female to male ratio of 1.63:1. The prevalence of comorbid depression was 22.8%, made up of mild (21.8%) and moderate (1.0%) depressive episodes only. Depression was commoner among females than males in a ratio of 3:1. A majority of the participants (96.8%) had high medication adherence; 2.8% and 0.4% had moderate and low adherence respectively. Depression was more among patients with good medication adherence.

Conclusion

The occurrence of mild depressive disorder among hypertensives did not affect the level of medication adherence. Review of Antihypertensive drugs should also be done often to ensure patients are not likely to have depressive illness as a side effect of drugs used.

Associations of major depressive disorder with chronic physical conditions, obesity and medication use: Results from the PISMA-ep study

BACKGROUND

Life expectancy of people with depression is on average 15 years less than that of the general population. This excess of mortality is largely attributed to a deteriorated physical health. Evidence about the association between major depressive disorder (MDD) and physical health is still lacking in some areas. The aim of this study was to explore the association between MDD and physical health-related variables in southern Spain.

METHODS

The PISMA-ep is a cross-sectional study based on community-dwelling adult population. Our main outcome was current prevalence of MDD. Independent variables explored were: lifetime prevalence of twenty-one chronic physical conditions (CPCs), anthropometric measures (height, weight, body max index, and hip and waist circumferences), general health status, and medication use.

RESULTS

MDD was significantly associated with any CPC (OR = 2.60; 95% CI: 2.01-3.35; p < 0.001). Increases in BMI were associated with MDD in women (OR=1.08; 95% CI: 1.05-1.11; p < 0.001), but not in men (OR=0.99; 95% CI: 0.95-1.05; p = 0.916). Variables associated with MDD in the multivariate model were: female gender, obesity, general health status, cancer, peptic ulcer, tinnitus and vertigo. 21.4% of participants with MDD received antidepressant treatment.

CONCLUSIONS

MDD is associated with CPCs, obesity, and increased use of medication. The high rates of comorbidity between MDD and CPCs call for a more holistic management of patients in the clinical practice. The low rate of antidepressant use may be indicating underdiagnosis. Anthropometric variables were differently associated with MDD depending on gender, suggesting a strong influence of psychosocial factors.

Beliefs and Adherence Associated With Oral and Infusion Chelation Therapies in Jordanian Children and Adolescents With Thalassemia Major: A Comparative Study

The researcher assessed the beliefs and adherence associated with both oral deferasirox and deferoxamine infusion chelation therapies among Jordanian children with thalassemia major, and compared the adherence levels between the recipients of each. In this descriptive cross-sectional study, 120 participants were recruited from 3 major thalassemia treatment clinics in Jordan using convenience sampling. Data were collected through questionnaires on demographic- and disease-related information, the beliefs about medicines, and a medication adherence report scale. Most participants showed a high adherence to deferoxamine infusion and oral deferasirox (87.20% and 89.08%, respectively), and believed in the necessity of deferoxamine for maintaining health (89.34%). However, 41.32% of the participants had strong concerns about deferoxamine use. While most participants believed in the need for oral deferasirox (89.84%), about 40.7% had strong concerns about its use. An independent samples t test showed no statistically significant difference in the adherence between the oral deferasirox and infusion deferoxamine recipients (t=1.048, DF=118, P=0.075). Jordanian children with thalassemia have positive beliefs and adherence to both oral and infusion chelation therapies. Health care providers should pay attention to patients' beliefs and discuss the major concerns pertaining to iron chelation therapy with them to enhance the continuity of adherence therapy.

Implementation Research Methodologies for Achieving Scientific Equity and Health Equity

Implementation science has great potential to improve the health of communities and individuals who are not achieving health equity. However, implementation science can exacerbate health disparities if its use is biased toward entities that already have the highest capacities for delivering evidence-based interventions. In this article, we examine several methodologic approaches for conducting implementation research to advance equity both in our understanding of what historically disadvantaged populations would need-what we call scientific equity-and how this knowledge can be applied to produce health equity. We focus on rapid ways to gain knowledge on how to engage, design research, act, share, and sustain successes in partnership with communities. We begin by describing a principle-driven partnership process between community members and implementation researchers to overcome disparities. We then review three innovative implementation method paradigms to improve scientific and health equity and provide examples of each. The first paradigm involves making efficient use of existing data by applying epidemiologic and simulation modeling to understand what drives disparities and how they can be overcome. The second paradigm involves designing new research studies that include, but do not focus exclusively on, populations experiencing disparities in health domains such as cardiovascular disease and co-occurring mental health conditions. The third paradigm involves implementation research that focuses exclusively on populations who have experienced high levels of disparities. To date, our scientific enterprise has invested disproportionately in research that fails to eliminate health disparities. The implementation research methods discussed here hold promise for overcoming barriers and achieving health equity.

‘You feel like you haven’t got any control’: A qualitative study of side effects from medicines

Objectives

An aging UK population and multi-morbidity means patients are receiving an increasing number of medicines. This can lead to greater risk of unintended side effects. The aim of this study was to increase understanding of how people identify and manage side effects from their medicines.

Design

A qualitative interview study with patients who had experienced side effects, recruited from community pharmacies.

Methods

This study examined patients’ experiences of side effects and the impact of these effects on their daily life. Fifteen participants were interviewed – 10 females and 5 males, with ages that ranged between 25 and 80 years, using different types and numbers of medicines.

Results

Thematic analysis revealed six themes: side effect experience, identification, adherence, information use, coping and body awareness. Participants described a wide range of physical and psychological symptoms which had both explicit and implicit impact on their lives. A system of identification based on constructed cognitive processes was common across participants. A variety of strategies were used by participants to cope with their side effects which included information seeking, social support seeking and non-adherent behaviours.

Conclusions

Psychological factors, such as medication beliefs, symptom interpretation and body awareness, contribute to cognitive and behavioural processes used to identify and manage side effects. These processes can have significant impacts on an individual’s decisions about adherence.

Clinical, Socioeconomic, and Psychosocial Factors Associated with Blood Pressure Control and Adherence: Results from a Multidisciplinary Cardiovascular National Program Providing Universal Coverage in a Developing Country

Background

Limited information exists on blood pressure (BP) control factors and adherence to antihypertensive drug therapy (Rx) in developing countries.

Methods

Cross-sectional study in randomly selected 992 hypertensive patients under a Chilean national comprehensive Cardiovascular Health Program (CVHP). Association of education, income, diabetes, obesity, physical activity, psychosocial characteristics, smoking, and alcohol abuse with BP control and adherence were evaluated by multivariate logistic regression.

Results

BP control (<140/90 mmHg) was achieved in 63.1% of patients, with 38.4% adherent to Rx. Uncontrolled BP significantly associated with male sex (OR: 1.73 [95% CI 1.35-2.22]), low family income, high emotional-stress-depression score, body mass index, no adherence (OR: 1.83 [95% CI 1.44 - 2.32]), multiple Rx, baseline systolic BP value, and sedentary life style. Males (OR: 1.54 [95% CI 1.23 - 1.93]), low family income, high emotional stress-depression score (OR: 2.15 [95% CI 1.68 - 2.76]), low social support, and uncontrolled BP (OR: 1.52 [95% CI 1.22-1.90]) associated with no adherence.

Conclusions

Comparable BP control (63.1%) to higher-income societies was observed. Uncontrolled BP associated significantly to no adherence and both to male sex, socioeconomic, and psychosocial factors. Global low adherence (38.4%) and improved BP control and adherence in diabetics were noted.

Beliefs about hydroxyurea in youth with sickle cell disease

BACKGROUND

Hydroxyurea reduces complications and improves health-related quality of life (HRQOL) in sickle cell disease (SCD) patients, however adherence remains suboptimal. Understanding patients' views of hydroxyurea is critical to optimize adherence, particularly in adolescents and young adults (AYA). Study objectives were to assess beliefs about hydroxyurea using the Beliefs about Medicines Questionnaire (BMQ), and to examine the relationship of patients' beliefs to their hydroxyurea adherence and HRQOL.

METHODS

Thirty-four AYA with SCD participated in a cross-sectional study January-December 2015. Study assessments included BMQ to examine beliefs about hydroxyurea; Visual Analogue Scale (VAS) to assess hydroxyurea adherence; and Patient Reported Outcomes Measurement Information System (PROMIS®) to evaluate HRQOL.

RESULTS

Participants (41% female, 91% Black) had median age of 13.5 (IQR 12-18) years. Participants' concerns about overuse of medications correlated with concerns about hydroxyurea (r_s = 0.36, p = 0.04) and overall harm of medications (r_s = 0.5, p = 0.003). Participants' age positively correlated with the necessity of hydroxyurea (r_s = 0.45, p = 0.007). Participants' concerns about hydroxyurea and overuse of medications positively correlated with anxiety (r_s = 0.41, p = 0.02; r_s = 0.44, p = 0.01) and depression (r_s = 0.37, p = 0.04; r_s = 0.54, p = 0.001), but inversely correlated with peer relationships (r_s = -0.45, p = 0.03; r_s = -0.44, p = 0.03), respectively, suggesting better HRQOL with concerns. Fifty percent of participants reported low hydroxyurea adherence (VAS < 80%), which was more seen in patients with higher concerns about hydroxyurea (p = 0.02).

CONCLUSIONS

Beliefs about hydroxyurea correlated with HRQOL scores and adherence levels. Addressing patients' concern about hydroxyurea and medications overall as well as routine assessment of adherence and beliefs could help to overcome adherence barriers.

Differences in Attitudes Toward Immunosuppressant Therapy in a Multi-ethnic Sample of Kidney Transplant Recipients

Barriers for renal transplant patients to immunosuppressant medication adherence are poorly understood, despite the high rate and toll of non-adherence. We sought to assess factors that contribute to barriers to immunosuppressive medication adherence in an ethnically diverse sample of 312 renal transplant patients recruited from three transplant centers across New York City. Transplant patients who were at least 6 months post-transplant completed questionnaires while waiting for their medical appointment. Ethnic differences were observed on barriers to immunosuppressant adherence. Black and Hispanic participants reported significantly more barriers to adherence compared to Caucasian participants. Differences in perception about the potential harm and necessity of immunosuppressant medications also were present. Using hierarchical multiple regression, age and income were significant predictors of reported barriers to adherence, even while controlling for ethnicity. The most robust predictor of reported barriers was the perception of the medication cost-benefit differential, i.e., the balance between concerns about immunosuppressant medications and their perceived helpfulness (B = - 0.5, p < .001), indicating that varying beliefs about the medication's necessity and utility rather than ethnicity explain the differences in barriers to medication adherence. Future interventions targeting non-adherence should aim to reduce the barriers to adherence by addressing perceived risks and benefits of taking immunosuppressant medication.

Is patient empowerment the key to promote adherence? A systematic review of the relationship between self-efficacy, health locus of control and medication adherence

Background

Current health policies emphasize the need for an equitable doctor-patient relationship, and this requires a certain level of patient empowerment. However, a systematic review of the empirical evidence on how empowerment affects medication adherence—the extent to which patients follow the physician’s prescription of medication intake—is still missing. The goal of this systematic review is to sum up current state-of-the-art knowledge concerning the relationship between patient empowerment and medication adherence across medical conditions. As our conceptualization defines health locus of control and self-efficacy as being crucial components of empowerment, we explored the relationship between these two constructs and medication adherence.

Methods

Relevant studies were retrieved through a comprehensive search of Medline and PsychINFO databases (1967 to 2017). In total, 4903 publications were identified. After applying inclusion and exclusion criteria and quality assessment, 154 articles were deemed relevant. Peer-reviewed articles, written in English, addressing the relationship between empowerment (predictor) and medication adherence (outcome) were included.

Findings

High levels of self-efficacy and Internal Health Locus of Control are consistently found to promote medication adherence. External control dimensions were found to have mainly negative (Chance and God attributed control beliefs) or ambiguous (Powerful others attributed control beliefs) links to adherence, except for Doctor Health Locus of Control which had a positive association with medication adherence. To fully capture how health locus of control dimensions influence medication adherence, the interaction between the sub-dimensions and the attitudinal symmetry between the doctor and patient, regarding the patient’s control over the disease management, can provide promising new alternatives.

Discussion

The beneficial effect of patients’ high internal and concurrent physician-attributed control beliefs suggests that a so-called “joint empowerment” approach can be suitable in order to foster medication adherence, enabling us to address the question of control as a versatile component in the doctor-patient relationship.

The impact of medication nonadherence on the relationship between mortality risk and depression in heart failure

OBJECTIVE

Heart failure affects more than 5 million U.S. adults, and approximately 20% of individuals with heart failure experience depressive symptoms. Depression is detrimental to prognosis in heart failure, conferring approximately a 2-fold increase in mortality risk. Medication nonadherence may help explain this relationship because depressed patients are less likely to adhere to the medication regimen.

METHOD

Depression, electronically monitored medication adherence, and mortality were measured in a sample of 308 patients with heart failure participating in a study of self-management behavior. Cardiovascular and all-cause mortality data were obtained from the Centers for Disease Control and Prevention's National Death Index (median 2.9-year follow-up). Cox proportional hazards regression was used to assess the relationship between depression and mortality, with and without adjustment for age, gender, disease severity, and medication nonadherence.

RESULTS

In adjusted analyses, depression was associated with an increased all-cause mortality risk (hazard ratio 1.87; 95% confidence interval 1.04-3.37). Depression was not related to cardiovascular mortality, potentially because of a low number of cardiac-related deaths. When medication nonadherence was added to the model, nonadherence (hazard ratio 1.01; 95% confidence interval 1.004-1.02), but not depression, predicted all-cause mortality risk.

CONCLUSIONS

Depressive symptoms confer increased all-cause mortality risk in heart failure, and medication nonadherence contributes to this relationship. Depression and nonadherence represent potentially modifiable risk factors for poor prognosis. Future research is needed to understand whether interventions that concomitantly target these factors can improve outcomes. (PsycINFO Database Record

The necessity-concerns framework predicts adherence to medication in multiple illness conditions: A meta-analysis

OBJECTIVE

This meta-analysis investigated whether beliefs in the necessity and concerns of medicine and the necessity-concerns differential are correlated with medication adherence on a population level and in different conditions.

METHODS

An electronic search of Web of Science, EMBASE, PubMed and CINAHL was conducted for manuscripts utilising the Beliefs about Medicines Questionnaire and comparing it to any measure of medication adherence. Studies were pooled using the random-effects model to produce a mean overall effect size correlation. Studies were stratified for condition, adherence measure, power and study design.

RESULTS

Ninety-four papers were included in the meta-analysis. The overall effect size(r) for necessity, concerns, and necessity-concerns differential was 0.17, -0.18 and 0.24 respectively and these were all significant (p<0.0001). Effect size for necessity was stronger in asthma and weaker in the cardiovascular group compared to the overall effect size.

CONCLUSION

Necessity and concerns beliefs and the necessity-concerns differential were correlated with medication adherence on a population level and across the majority of included conditions. The effect sizes were mostly small with a magnitude comparable to other predictors of adherence.

PRACTICE IMPLICATIONS

This meta-analysis suggests that necessity and concern beliefs about medicines are one important factor to consider when understanding reasons for non-adherence.

Applications of Text Messaging, and Bibliotherapy for Treatment of Patients Affected by Depressive Symptoms

BACKGROUND

Intensity of depressive symptoms could be exacerbated due to the paucity of appropriate treatments. We assessed the effectiveness of bibliotherapy and text messaging, which aimed at amelioration of patient's behavior and consciousness, which could lead to suicide prevention.

METHODS

This was a randomized clinical trial implemented in rural health centers of Isfahan district (Iran). Health centers were assigned in three trials consisting of the booklet, text messaging, and control groups. Each group consisted of 70 patients. Inclusion criteria were being affected by depressive symptom, <18 years, and cell phone accessibility. Mental retardation, drug and alcohol abuse, visual disability, dementia, suicide attempt history, electrotherapy, and receiving psychological interventions were our not met criteria. Our patient outcomes comprised intensity of depressive symptom and treatment compliance. The first two trials were requested to study instructive booklets in 30 days while the second cohort was demanded to study the booklet in accordance with the daily delivered text messaging.

RESULTS

Out of 210 individuals, 198 patients finished this study. The intensity of depressive symptom was significantly affected through time and group factors as well as time-group interaction (F = 12.30, P < 0.001). Based on treatment compliance, the interactive effect of group factor and the time factor was statistically significant.

CONCLUSIONS

It seems that bibliotherapy could efficiently decrease the intensity of depressive symptoms. Nevertheless, in comparison with our booklet trial, the text messaging group achieved neither durable nor significant success; thus, bibliotherapy could be utilized as a complementary methodology aiming depression treatment.

A systematic review of physical illness, functional disability, and suicidal behaviour among older adults

OBJECTIVES

To conduct a systematic review of studies that examined associations between physical illness/functional disability and suicidal behaviour (including ideation, nonfatal and fatal suicidal behaviour) among individuals aged 65 and older.

METHOD

Articles published through November 2014 were identified through electronic searches using the ERIC, Google Scholar, PsycINFO, PubMed, and Scopus databases. Search terms used were suicid* or death wishes or deliberate self-harm. Studies about suicidal behaviour in individuals aged 65 and older with physical illness/functional disabilities were included in the review.

RESULTS

Sixty-five articles (across 61 independent samples) met inclusion criteria. Results from 59 quantitative studies conducted in four continents suggest that suicidal behaviour is associated with functional disability and numerous specific conditions including malignant diseases, neurological disorders, pain, COPD, liver disease, male genital disorders, and arthritis/arthrosis. Six qualitative studies from three continents contextualized these findings, providing insights into the subjective experiences of suicidal individuals. Implications for interventions and future research are discussed.

CONCLUSION

Functional disability, as well as a number of specific physical illnesses, was shown to be associated with suicidal behaviour in older adults. We need to learn more about what at-risk, physically ill patients want, and need, to inform prevention efforts for older adults.

Effects of stress, health competence, and social support on depressive symptoms after cardiac hospitalization

Little is known about the role of stress on the psychological well-being of patients after cardiac hospitalization or about factors that protect against or exacerbate the effects of stress. We use prospective data from 1542 patients to investigate the relationship between post-discharge stress and changes in depressive symptoms, and whether the level of prior depressive symptoms, health competence, and perceived social support moderate this relationship. Net of depressive symptoms in the 2 weeks prior to hospitalization, higher levels of post-discharge stress significantly increase depressive symptoms 30 days after discharge. The level of prior depressive symptoms moderates the effect of stress. On the other hand, perceived health competence and social support buffer the negative effects of post-discharge stress. Knowing which patients are particularly vulnerable to experiencing stress and a subsequent increase in depressive symptoms can help trigger interventions prior to discharge and possibly ameliorate the prevalence of depression.

Depressive symptoms in heart failure: Independent prognostic factor or marker of functional status?

OBJECTIVE

The prognostic potential of depressive symptoms independent of somatic features of heart failure severity has repeatedly been demonstrated. However, patient-reported functional status has rarely been accounted for in these studies. Thus, it has remained unclear to what extent the predictive power of depressive symptoms may mirror functional status. We therefore aimed to evaluate the prognostic value of depressive symptoms adjusting for patient-reported functional status in a large, well-characterized sample of patients with systolic heart failure.

METHODS

Eight hundred sixty-three patients, 67±12 years old, 72% men, and 42% with New York Heart Association functional classes III/IV, who participated in the extended Interdisciplinary Network Heart Failure (INH) study were investigated. We assessed depressive symptoms using the Patient Health Questionnaire (PHQ-9) and patient-reported functional status with the Kansas City Cardiomyopathy Questionnaire (KCCQ). Data on survival was obtained after a follow-up of 18 months (100% complete).

RESULTS

Depressive symptoms predicted mortality risk (HR per PHQ-9 scale point=1.07, 95% CI 1.04-1.09, p<.001), even after adjustment for heart failure severity and co-morbidities (HR=1.04, 95% CI 1.01-1.07, p=.017). However, they were no longer significant predictors (HR=1.01, 95% CI 0.98-1.05, p=0.46) after additional adjustment for patient-reported functional status, which proved predictive of mortality risk (HR=0.90, 95% CI 0.82-0.99, p=.025).

CONCLUSION

Our results suggest that the association of depressive symptoms with functional status may at least partly explain the prognostic potential of depressive symptoms.

Web-based interventions for comorbid depression and chronic illness: a systematic review

Web-based interventions offer potential benefits for managing and treating depression in the context of chronic physical illness, however their use with this population has yet to be quantitatively assessed. The present systematic review examined the biopsychosocial data from 11 independent studies (N = 1348 participants), including randomised controlled and quasi-experimental designs most commonly performed with diabetes and multiple sclerosis. Study quality was evaluated using the Downs and Black (1998) index, with most studies being statistically underpowered although internal validity was demonstrated. Treatment outcomes were quantified using Cohen's d effect sizes. Results indicated significant short-term improvements in depression severity (d w = 0.36, CI = 0.20-0.52, p < 0.01), in addition to quality of life, problem-solving skills, functional ability, anxiety and pain-related cognitions (d range = 0.23 to 1.10). Longer-term outcomes could not be determined based on the limited data. Further robust studies are required before wider adoption of web techniques takes place.

Mental health in hypertension: assessing symptoms of anxiety, depression and stress on anti-hypertensive medication adherence

Background

Patients with chronic conditions like hypertension may experience many negative emotions which increase their risk for the development of mental health disorders particularly anxiety and depression. For Ghanaian patients with hypertension, the interaction between hypertension and symptoms of anxiety, depression and stress remains largely unexplored. To fill this knowledge gap, the study sought to ascertain the prevalence and role of these negative emotions on anti-hypertensive medication adherence while taking into account patients’ belief systems.

Methods

The hospital-based cross-sectional study involving 400 hypertensive patients was conducted in two tertiary hospitals in Ghana. Data were gathered on patient’s socio-demographic characteristics, anxiety, depression and stress symptoms, spiritual beliefs, and medication adherence.

Results

Hypertensive patients experienced symptoms of anxiety (56%), stress (20%) and depression (4%). As a coping mechanism, a significant relation was observed between spiritual beliefs and anxiety (x² = 13.352, p = 0.010), depression (x² = 6.205, p = 0.045) and stress (x² = 14.833, p = 0.001). Stress among patients increased their likelihood of medication non-adherence [odds ratio (OR) = 2.42 (95% CI 1.06 – 5.5), p = 0.035].

Conclusion

The study has demonstrated the need for clinicians to pay attention to negative emotions and their role in medication non-adherence. The recommendation is that attention should be directed toward the use of spirituality as a possible mechanism by which negative emotions could be managed among hypertensive patients.

Psychosocial factors and medication adherence among patients with coronary heart disease: A text messaging intervention

OBJECTIVE

Medication adherence is a complex behavior that is influenced by numerous factors. Applying self-efficacy theory, the primary aim of this randomized controlled trial was to compare medication self-efficacy among patients with coronary heart disease who received: (a) text messages (TMs) for medication reminders and education, (b) TMs for education, or (c) no TMs. The second aim was to identify the personal (sociodemographic and clinical characteristics) and psychosocial factors that were associated with and predicted medication adherence.

METHODS

Customized TMs were delivered over 30 days. Repeated measures analysis of variance was used to analyze medication self-efficacy. A multiple regression analysis was performed at baseline and follow-up to determine variables that were associated with and predicted self-reported medication adherence.

RESULTS

Among 90 subjects with mean age 59.2 years (standard deviation (SD) 9.4, range 35-83), total scores for medication self-efficacy improved over 30 days; however, there was no significant difference in this improvement as a function of the different treatment groups (p=0.64). Controlling for other variables in the model (age, education, depression, and social support), less depression (p=0.004) and higher social support (p=0.02) positively predicted higher medication adherence in the final model.

CONCLUSIONS

TM medication reminders and/or health education did not improve medication self-efficacy. Further theory testing of current and future models and interventions are required to understand variables related to self-efficacy and medication adherence. Addressing psychosocial factors such as depression and social support should be a priority to improve medication adherence among patients with coronary heart disease.

Non-adherence in patients on peritoneal dialysis: a systematic review

BACKGROUND

It has been increasingly recognized that non-adherence is an important factor that determines the outcome of peritoneal dialysis (PD) therapy. There is therefore a need to establish the levels of non-adherence to different aspects of the PD regimen (dialysis procedures, medications, and dietary/fluid restrictions).

METHODS

A systematic review of peer-reviewed literature was performed in PubMed, PsycINFO and CINAHL databases using PRISMA guidelines in May 2013. Publications on non-adherence in PD were selected by two reviewers independently according to predefined inclusion and exclusion criteria. Relevant data on patient characteristics, measures, rates and factors associated with non-adherence were extracted. The quality of studies was also evaluated independently by two reviewers according to a revised version of the Effective Public Health Practice Project assessment tool.

RESULTS

The search retrieved 204 studies, of which a total of 25 studies met inclusion criteria. Reported rates of non-adherence varied across studies: 2.6-53% for dialysis exchanges, 3.9-85% for medication, and 14.4-67% for diet/fluid restrictions. Methodological differences in measurement and definition of non-adherence underlie the observed variation. Factors associated with non-adherence that showed a degree of consistency were mostly socio-demographical, such as age, employment status, ethnicity, sex, and time period on PD treatment.

CONCLUSION

Non-adherence to different dimensions of the dialysis regimen appears to be prevalent in PD patients. There is a need for further, high-quality research to explore these factors in more detail, with the aim of informing intervention designs to facilitate adherence in this patient population.

Effect of depression onset on adherence to medication among hypertensive patients: a longitudinal modelling study

OBJECTIVES

Although a link between depression and poor adherence to antihypertensive medication (AHM) has been found, it is not known whether depression actually leads to poorer adherence or whether poor adherence only is a marker of depression. In this study we aimed to determine the time order between hypertension, depression and changes in adherence to AHM.

METHODS

The analyses were based on data gathered from a longitudinal cohort of Finnish employees (The Finnish Public Sector Study). A total of 852 chronically hypertensive men and women at baseline with a recorded onset of depression during the 9-year observation window and 2359 hypertensive control participants matched for age, sex, socio-economic status, time of study entry, employer and geographic area were included in the study. Individuals with any sign of depression during 4 years before the beginning of the study were excluded. To describe long-term trajectories (4 years before and 4 years after the recorded depression) of AHM adherence in relation to the onset of depression, annual data on reimbursed AHM prescriptions were gathered from the national Drug Prescription Register. Annual nonadherence rates (i.e. number of 'days-not-treated') were based on filled prescriptions.

RESULTS

Among male cases, the rate of 'days-not-treated' was 1.52 times higher (95% confidence interval 1.08-2.14) in the years after the onset of depression compared to preonset levels. In women and in male controls, no change in adherence to AHM was observed between these time periods.

CONCLUSION

In hypertensive men, the onset of recorded depression increases the risk of nonadherence to AHM.

Understanding patients' adherence-related beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the Necessity-Concerns Framework

BACKGROUND

Patients' beliefs about treatment influence treatment engagement and adherence. The Necessity-Concerns Framework postulates that adherence is influenced by implicit judgements of personal need for the treatment (necessity beliefs) and concerns about the potential adverse consequences of taking it.

OBJECTIVE

To assess the utility of the NCF in explaining nonadherence to prescribed medicines.

DATA SOURCES

We searched EMBASE, Medline, PsycInfo, CDSR/DARE/CCT and CINAHL from January 1999 to April 2013 and handsearched reference sections from relevant articles.

STUDY ELIGIBILITY CRITERIA

Studies using the Beliefs about Medicines Questionnaire (BMQ) to examine perceptions of personal necessity for medication and concerns about potential adverse effects, in relation to a measure of adherence to medication.

PARTICIPANTS

Patients with long-term conditions.

STUDY APPRAISAL AND SYNTHESIS METHODS

Systematic review and meta-analysis of methodological quality was assessed by two independent reviewers. We pooled odds ratios for adherence using random effects models.

RESULTS

We identified 3777 studies, of which 94 (N = 25,072) fulfilled the inclusion criteria. Across studies, higher adherence was associated with stronger perceptions of necessity of treatment, OR = 1.742, 95% CI [1.569, 1.934], p<0.0001, and fewer Concerns about treatment, OR = 0.504, 95% CI: [0.450, 0.564], p<0.0001. These relationships remained significant when data were stratified by study size, the country in which the research was conducted and the type of adherence measure used.

LIMITATIONS

Few prospective longitudinal studies using objective adherence measures were identified.

CONCLUSIONS

The Necessity-Concerns Framework is a useful conceptual model for understanding patients' perspectives on prescribed medicines. Taking account of patients' necessity beliefs and concerns could enhance the quality of prescribing by helping clinicians to engage patients in treatment decisions and support optimal adherence to appropriate prescriptions.

Help needed in medication self-management for people with visual impairment: case-control study

BACKGROUND

Visual impairment (VI) is rising in prevalence and contributing to increasing morbidity, particularly among older people. Understanding patients' problems is fundamental to achieving optimal health outcomes but little is known about how VI impacts on self-management of medication.

AIM

To compare issues relating to medication self-management between older people with and without VI.

DESIGN AND SETTING

Case-control study with participants aged ≥65 years, prescribed at least two long-term oral medications daily, living within the community.

METHOD

The study recruited 156 patients with VI (best corrected visual acuity [BCVA] 6/18 to 3/60) at low-vision clinics; community optometrists identified 158 controls (BCVA 6/9 or better). Researchers visited participants in their homes, administered two validated questionnaires to assess medication adherence (Morisky; Medication Adherence Report Scale [MARS]), and asked questions about medication self-management, beliefs, and support.

RESULTS

Approximately half of the participants in both groups reported perfect adherence on both questionnaires (52.5% Morisky; 43.3%, MARS). Despite using optical aids, few (3%) with VI could read medication information clearly; 24% had difficulty distinguishing different tablets. More people with VI (29%) than controls (13%) (odds ratio [OR] = 2.8; 95% confidence interval [CI] = 1.6 to 5.0) needed help managing their medication, from friends (19% versus 10%) or pharmacists (10% versus 2.5%; OR = 4.4, 95% CI = 1.4 to 13.5); more received social service support (OR = 7.1; 95% CI = 3.9 to 12.9).

CONCLUSION

Compared to their peers without VI, older people with VI are more than twice as likely to need help in managing medication. In clinical practice in primary care, patients' needs for practical support in taking prescribed treatment must be recognised. Strategies for effective medication self-management should be explored.

Beliefs about chelation among thalassemia patients

Background

Understanding patients’ views about medication is crucial to maximize adherence. Thalassemia is a congenital blood disorder requiring chronic blood transfusions and daily iron chelation therapy.

Methods

The Beliefs in Medicine Questionnaire (BMQ) was used to assess beliefs in chelation in thalassemia patients from North America and London in the Thalassemia Longitudinal Cohort (TLC) of the Thalassemia Clinical Research Network (TCRN). Chelation adherence was based on patient report of doses administered out of those prescribed in the last four weeks.

Results

Of 371 patients (ages 5-58y, mean 24y), 93% were transfused and 92% receiving chelation (26% deferoxamine (DFO; a slow subcutaneous infusion via portable pump), 63% oral, 11% combination). Patients expressed high “necessity” for transfusion (96%), DFO chelation (92%) and oral chelation (89%), with lower “concern” about treatment (48%, 39%, 19% respectively). Concern about oral chelation was significantly lower than that of DFO (p<0.001). Self-reported adherence to chelation was not associated with views about necessity or concerns, but negatively correlated with perceived sensitivity to DFO (Sensitive Soma scale; r=−0.23, p=0.01) and side effects of oral chelation (r=−0.14, p=0.04). High ferritin iron levels, potentially indicating lower adherence, were found in 41% of patients reporting low necessity of oral chelation compared to 24% reporting high necessity (p=0.048). Concerns about treatment were associated with lower quality of life and more symptoms of anxiety and depression.

Conclusions

Despite their requirement for multimodal therapy, thalassemia patients have positive views about medicine, more so than in other disease populations. Patients may benefit from education about the tolerability of chelation and strategies to effectively cope with side effects, both of which might be beneficial in lowering body iron burden.

Clinicaltrials.gov identifier

NCT00661804

Utility of the Millon Behavioral Medicine Diagnostic to predict medication adherence in patients diagnosed with heart failure

Medication non-adherence is common and a primary reason for poor medical outcomes among individuals with heart failure (HF). This study's aims were to determine whether depression, hostility, and the personality-based Millon Behavioral Medicine Diagnostic (MBMD) Medication Abuse scale were associated with medication adherence (e.g., beta-blockers, ACE inhibitors, diuretics, statins) beyond contributions of demographic, medical, and psychosocial variables in an ethnically-diverse sample of 105 men and women diagnosed with HF. In hierarchical regression, greater MBMD Medication Abuse scale scores were associated with poorer adherence above and beyond both depression (β = .236, t[102] = 2.113, p = .037) and hostility (β = .244, t[102] = 2.506, p = .014). The Medication Abuse scale also completely mediated the relationship between adherence and depression. These findings suggest that personality measures such as the MBMD and hostility scales might be utilized in future studies investigating predictors of adherence and also used clinically to predict medication adherence among HF patients.

Medication beliefs predict medication adherence in older adults with multiple illnesses

OBJECTIVE

To examine factors preventing medication nonadherence in community-dwelling older adults with multiple illnesses (multimorbidity). Nonadherence threatens successful treatment of multimorbidity. Adherence problems can be intentional (e.g., deliberately choosing not to take medicines or to change medication dosage) or unintentional (e.g., forgetting to take medication) and might depend on a range of factors. This study focused in particular on the role of changes in beliefs about medication to explain changes in adherence.

METHODS

Longitudinal study with N = 309 individuals aged 65-85 years with two or more diseases at three measurement points over six months. Medication adherence and beliefs about medicines were assessed by questionnaire. Hierarchical weighted least squares regression analyses were used to predict individual intentional and unintentional nonadherence.

RESULTS

Changes in intentional nonadherence were predicted by changes in specific necessity beliefs (B = -.19, P<.01), after controlling for sociodemographic factors, health status and number of prescribed medicines. Changes in unintentional nonadherence were predicted by changes in general overuse beliefs (B = .26, P<.01), controlling for the same covariates.

CONCLUSION

Beliefs about medication affect both intentional and unintentional adherence to medication in multimorbid older adults. This points to the importance of addressing medication beliefs in patient education to improve adherence.

Impact of depression and social support on nonadherence to antipsychotic drugs in persons with schizophrenia in Thailand

BACKGROUND

Little is known about the effect of social support on nonadherence in persons with schizophrenia, especially in developing Asian countries where social support is considered to be imperative. Additionally, the role of depression as a mediator in the association between social support deficits and nonadherence has not been evaluated.

METHODS

This was a cross-sectional study conducted in 75 participants at a university hospital in Thailand. Logistic regression was used to determine whether depression and a deficit in social support were associated with nonadherence, and whether depression mediated this association.

RESULTS

There were strong relationships between nonadherence and major depressive episodes (odds ratio [OR] 9.5, confidence interval [CI] 2.3-38.9), living alone (OR 21.8, CI 3.5-143.0), and dissatisfaction with support from family (OR 10.0, CI 1.9-53.1). The OR of the association between social support deficits and nonadherence decreased by nearly one half after adjusting for depression.

DISCUSSION

Depression and social support deficits were significantly associated with nonadherence in persons with schizophrenia. Depression is important in mediating the association between social support deficits and nonadherence. Enhancing social support, as well as early detection and effective intervention for depression should be emphasized in interventions to improve adherence in persons with schizophrenia.

Patient attitudinal and behavioral factors associated with warfarin non-adherence at outpatient anticoagulation clinics

BACKGROUND

Warfarin is an anticoagulant effective in preventing stroke, but it has a narrow therapeutic range requiring optimal adherence to achieve the most favorable effects.

PURPOSE

The goal of this study was to examine specific patient factors that might help explain warfarin non-adherence at outpatient anticoagulation clinics.

METHOD

In a prospective cohort study of 156 adults, we utilized logistic regression analyses to examine the relationship between the five Treatment Prognostics scales from the Millon Behavioral Medicine Diagnostic (MBMD), as well as three additional MBMD scales (Depression, Future Pessimism, and Social Isolation), and daily warfarin non-adherence assessed using electronic medication event monitoring systems caps over a median of 139 days.

RESULTS

Four of the five Treatment Prognostic scales and greater social isolation were associated with warfarin non-adherence. When controlling for pertinent demographic and medical variables, the Information Discomfort scale remained significantly associated with warfarin non-adherence over time.

CONCLUSION

Although several factors were related to warfarin non-adherence, patients reporting a lack of receptivity to details regarding their medical illness seemed most at risk for warfarin non-adherence. This information might aid in the development of interventions to enhance warfarin adherence and perhaps reduce adverse medical events.

Temporal stability of beliefs about medicines: implications for optimising adherence

OBJECTIVE

To compare beliefs about medicines, as measured by the BMQ-General questionnaire, at two time points for the same respondents.

METHODS

Respondents completed the BMQ-General as part of two separate postal questionnaires, administered with an intervening period of almost 4 years. BMQ-General scores were compared for all respondents at the two time points (2002 and 2005). Scores were also compared for three mutually exclusive groups based on changes in self-reported health status (better, worse or no change) during the intervening period.

RESULTS

BMQ-General scores remained stable over time: no statistically significant differences were observed in individuals' scores after almost 4 years. This finding persisted amongst respondents who reported changes in health status during the intervening period.

CONCLUSION

General beliefs about medicines appear to remain stable over time, irrespective of changes in health status. Further research should be done to establish whether specific beliefs about medicines prescribed for individuals are similarly stable.

PRACTICE IMPLICATIONS

Adherence is known to be associated with beliefs about medicines. The observed stability in such beliefs could have implications for the design of interventions to improve adherence to prescribed medication regimes.

A structured questionnaire to assess patient compliance and beliefs about medicines taking into account the ordered categorical structure of data

RATIONALE, AIMS AND OBJECTIVE

The objectives were to describe and evaluate the structured medication questionnaire and to improve data handling of results from the Morisky four-item scale for patient compliance and Beliefs about Medicines Questionnaire-specific (BMQ-specific).

METHODS

A questionnaire was developed with the purpose of being used when identifying medication errors and assessing patient compliance to and beliefs about medicines.

RESULTS

A majority of the respondents (62%; CI 45-77%) had at least one medication error. Assuming that all items are equally important in the Morisky four-item scale we presented four alternative ways to create a unidimensional global scale. A two-dimensional global scale was also constructed. The results from the BMQ-specific were presented in different ways, all taking into account that the scale has ordered verbal categories: at the level addressing each specific question, at the sub-scales 'concern' and 'necessity' level and at the global level.

CONCLUSIONS

The structured medication questionnaire can be used in daily practice as a tool to identify drug-related problems. The choice of how to use and present data from those scales in research depends on patient characteristics and how discriminating one would like the scales to be.