Medication adherence interventions that target subjects with adherence problems: Systematic review and meta-analysis

The indirect effect of nonadherence on health-related quality of life in older adults with neurological disorders: implications for clinical endpoints and interventions

Objective

This study assessed how Health-Related Quality of Life (HRQoL) and nonadherence to medication are linked, to determine whether HRQoL is a suitable endpoint for clinical trials evaluating nonadherence.

Background

HRQoL is often used as an endpoint in clinical trials to determine the effectiveness of nonadherence interventions. However, the relationship between HRQoL and nonadherence is not clear, as some interventions find an effect of nonadherence on HRQoL while others do not. Since both HRQoL and nonadherence are latent constructs, it is of interest to understand the factors that link them.

Methods

Medication nonadherence was assessed in 731 older adults with neurological disorders using the Stendal Adherence to Medication Score (SAMS). Regression and network analyses were performed to examine the association between the SAMS and HRQoL (SF-36). Cognitive function, depressive symptoms, mobility, and healthcare satisfaction were included as covariates.

Results

There was a weak association between the SAMS and HRQoL only for the mental component scale. The relationship between the SAMS and HRQoL appears indirect, as its effect is nullified upon the inclusion of covariates, especially depressive symptoms. Network analyses showed that the effect of nonadherence on HRQoL is mainly delivered by depressive symptoms, while cognition and satisfaction with healthcare contribute to a lesser extent.

Conclusion

Nonadherence and HRQoL are both latent variables influenced by similar factors. The effect of nonadherence on HRQoL seems to be indirect and mainly delivered by depressive symptoms, possibly via motivational pathways. These associations need to be considered when selecting clinical endpoints and planning interventions.

Evaluating the effectiveness of the Smart About Meds (SAM) mobile application among patients discharged from hospital: protocol of a randomised controlled trial

INTRODUCTION

Almost half of patients discharged from hospital are readmitted or return to the emergency department (ED) within 90 days. Non-adherence to medication changes made during hospitalisation and the use of potentially inappropriate medications (PIMs) both contribute to postdischarge adverse events. We developed Smart About Meds (SAM), a patient-centred mobile application that targets medication non-adherence and PIMs use. This protocol describes a randomised controlled trial (RCT) to evaluate SAM.

METHODS AND ANALYSIS

A pragmatic, stratified RCT will evaluate SAM among 3250 adult patients discharged from hospital. At discharge, consenting participants will be randomised 1:1 to usual care or SAM. SAM integrates novel patient-centred features with pharmacist monitoring to manage non-adherence to new medication regimens. SAM also notifies patients of PIMs in their regimen, with advice to discuss with their physician.Following discharge, patients will be followed for 90 days to measure the primary composite outcome of ED visits, hospital readmissions and death. Secondary outcomes will include primary adherence to medication changes, secondary adherence to disease-modifying medications, patient empowerment and health-related quality of life.The primary outcome will be analysed according to intention-to-treat. Multivariable logistic regression will estimate differences between treatment groups in the proportion of patients experiencing the primary outcome and will assess modification of intervention effects by hospital, unit, age, sex and comorbidity burden. With a sample size of 3250, the study will have 80% power to detect a 5% absolute reduction in the primary outcome. Binary and continuous secondary outcomes will be assessed using multivariable logistic and linear regression, respectively.

ETHICS AND DISSEMINATION

The Research Ethics Board of the McGill University Health Centre in Montréal, Canada has approved this study. Results will be submitted for publication in a peer-reviewed journal and presented at scientific conferences. If effective, SAM will be made available in app stores.

TRIAL REGISTRATION NUMBER

NCT05371548.

Enhancing medication adherence: A family-centered co-designed mHealth app for children undergoing hematopoietic stem cell transplant

BACKGROUND

High rates of medication non-adherence (52-73 %) in pediatric hematopoietic stem cell transplant (HCT), due to complex regimens and forgetfulness, increase life-threatening risks.

PURPOSE

This mixed methods study aimed to develop and evaluate the usability of the BMT4me© mobile health application to enhance adherence to immunosuppressants in children undergoing HCT.

DESIGN AND METHODS

A mixed methods, cross-sectional, iterative approach, with caregiver-child dyads and healthcare providers, was used to create the BMT4me© app prototype. This iterative approach involved continuously refining the app based on feedback from stakeholders at each phase. The process was user-centered, engaging patients, caregivers and healthcare providers in each stage. In phase 1, caregiver/child dyads (ages 8-17, n = 14) provided feedback on wireframes via qualitative interviews, which informed prototype development. Phase 2 involved focus groups with healthcare providers including physicians (n = 3), nurses (n = 15), and advanced practice nurses (n = 3) who evaluated the prototype's usability and provided feedback via reaction cards and the System Usability Scale (SUS). The System Usability Scale (SUS) measured usability, and thematic analysis identified key themes regarding engagement, ease of use, safety, and helpfulness. Quantitative data were analyzed using descriptive statistics, while qualitative data were thematically analyzed with NVivo software.

RESULTS

The mean SUS score from healthcare providers was 84.2, notably higher than the average expected score of 68, indicating successful usability of the BMT4me app. Thematic analysis highlighted themes of engagement, ease of use, and safety among providers, and ease of use and helpfulness among children and caregivers. This feedback refined the app to better serve families, patients, and providers.

PRACTICE IMPLICATIONS

The BMT4me© app shows promise in improving medication adherence in pediatric HCT patients. Integrating such mHealth applications into clinical practice will support adherence and improve outcomes in patients with high-risk, complex regimens. This app will guide practical implications and effectiveness of digital health tools.

CONCLUSIONS

A user-centered design approach, involving multiple stakeholders, was essential in developing BMT4me app. Feedback facilitated enhancements in app features and functionality. Pilot feasibility testing with caregivers is ongoing. Future research will assess the efficacy of digital interventions on clinical outcomes in children with complex treatment regimens.

Adapting malaria indicator surveys to investigate treatment adherence: a pilot study on Bioko Island, Equatorial Guinea

BACKGROUND

Adherence to anti-malarial treatment regimens is an important aspect of understanding and improving the impact of malaria case management. However, both adherence to artemisinin-based combination therapy (ACT) and the factors driving it vary widely. While many other evaluation activities have been conducted on Bioko Island, until now adherence to anti-malarial treatments, and in particular ACT has not been evaluated.

METHODS

The implementation of a malaria indicator survey (MIS) conducted on Bioko in 2023 was leveraged to evaluate adherence to ACT provided to individuals testing positive following the survey. A follow-up team visited the targeted households, physically observed treatment blisters where possible, and provided messaging to household members on the importance of adhering to the treatment guidelines to household members. The team used survey data from the targeted households to make messaging as relevant to the household's particular context as possible.

RESULTS

Overall ACT adherence on Bioko Island was low, around 50%, and this varied demographically and geographically. Some of the highest transmission areas had exceptionally low adherence, but no systematic relationship between proper adherence and Plasmodium falciparum prevalence was detected. Estimates of adherence from follow-up visits were much lower than survey-based estimates in the same households (52.5% versus 87.1%), suggesting that lack of proper adherence may be a much larger issue on Bioko Island than previously thought.

CONCLUSION

Representative surveys can be easily adapted to provide empirical estimates of adherence to anti-malarial treatments, complementary to survey-based and health facility-based estimates. The large discrepancy between adherence as measured in this study and survey-based estimates on Bioko Island suggests a health facility-based study to quantify adherence among the population receiving treatment for symptomatic malaria may be necessary.

Fostering active choice to empower behavioral change to reduce cardiovascular risk: A web-based randomized controlled trial

OBJECTIVE

To investigate the effect of an active choice (AC) intervention based on creating risk and choice awareness-versus a passive choice (PC) control group-on intentions and commitment to cardiovascular disease (CVD) risk-reducing behavior.

METHODS

Adults aged 50-70 (n = 743) without CVD history participated in this web-based randomized controlled trial. The AC intervention included presentation of a hypothetical CVD risk in a heart age format, information about CVD risk and choice options, and a values clarification exercise. The PC group received a hypothetical absolute numerical CVD risk and brief information and advice about lifestyle and medication. Key outcomes were reported degree of active choice, intention strength, and commitment to adopt risk-reducing behavior.

RESULTS

More AC compared to PC participants opted for lifestyle change (OR = 2.86, 95%CI:1.51;5.44), or lifestyle change and medication use (OR = 2.78, 95%CI:1.42;5.46), than 'no change'. No differences were found for intention strength. AC participants made a more active choice than PC participants (β = 0.09, 95%CI:0.01;0.16), which was sequentially mediated by cognitive risk perception and negative affect. AC participants also reported higher commitment to CVD risk-reducing behavior (β = 0.32, 95%CI:0.04;0.60), mediated by reported degree of active choice.

CONCLUSIONS

Fostering active choices increased intentions and commitment towards CVD risk-reducing behavior. Increased cognitive risk perception and negative affect were shown to mediate the effect of the intervention on degree of active choice, which in turn mediated the effect on commitment. Future research should determine whether fostering active choice also improves risk-reducing behaviors in individuals at increased CVD risk in real-life settings.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05142280. Prospectively registered.

Attitudes of patients with schizophrenia spectrum or bipolar disorders towards medication self-management during hospitalisation

BACKGROUND

Medication self-management (MSM) is defined as a person's ability to cope with medication treatment for a chronic condition, along with the associated physical and psychosocial effects that the medication causes in their daily lives. For many patients, it is important to be able to self-manage their medication successfully, as they will often be expected to do after discharge.

AIM

The aim of this study was to describe the willingness and attitudes of patients with schizophrenia spectrum or bipolar disorders regarding MSM during hospital admission. A secondary aim was to identify various factors associated with patient willingness to participate in MSM and to describe their assumptions concerning needs and necessary conditions, as well as their attitudes towards their medication.

METHODS

A multicentre, quantitative cross-sectional observational design was used to study the willingness and attitudes of psychiatric patients regarding MSM during hospitalisation. The study adhered to guidelines for Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

RESULTS

In this study, 84 patients, of which 43 were patients with schizophrenia spectrum disorders and 41 were patients with bipolar disorders, participated. A majority of the patients (81%) were willing to participate in MSM during their hospitalisation. Analysis revealed patients are more willing to MSM if they are younger (r = -.417, p < .001) and a decreasing number of medicines (r = -.373, p = .003). Patients' willingness was positively associated with the extent of support by significant others during and after hospitalisation (Pearson's r = .298, p = .011). Patients were convinced that they would take their medication more correctly if MSM were to be allowed during hospitalisation (65%).

CONCLUSION

Most of the patients were willing to self-manage their medication during hospitalisation, however, under specific conditions such as being motivated to take their medication correctly and to understand the benefits of their medication.

RELEVANCE TO CLINICAL PRACTICE

From a policy point of view, our study provided useful insights into how patients look at MSM to enable the development of future strategies. Since patients are willing to self-manage their medication during hospitalisation, this may facilitate its implementation.

PATIENT CONTRIBUTION

Patients were recruited for this study. Participation was voluntary, and signed informed consent was obtained from all participants prior to the questionnaire.

A machine-learning assisted review of the use of habit formation in medication adherence interventions for long-term conditions

Adherence to medication in long-term conditions is around 50%. The key components of successful interventions to improve medication adherence remain unclear, particularly when examined over prolonged follow-up periods. Behaviour change theories are increasingly interested in the utility of habit formation for the maintenance of health behaviour change, but there is no documentation on how habit has been conceptualised in the medication adherence intervention literature, or what effect the key technique identified in habit formation theory (context dependent repetition) has in these studies. To examine this, a machine-learning assisted review was conducted. Searches of MEDLINE, EMBASE and PSYCInfo and the reference list of a comprehensive systematic review of medication adherence interventions yielded 5973 articles. Machine learning-assisted title and abstract screening identified 15 independent RCTs published between 1976 and 2021, including 18 intervention comparisons of interest. Key findings indicate that conceptualisations of habit in the medication adherence literature are varied and behaviour change technique coding identified only six studies which explicitly described using habit formation. Future work should aim to develop this evidence base, drawing on contemporary habit theory and with explicit demonstration of what techniques have been used to promote habit formation.

What is the quantity, quality and type of systematic review evidence available to inform the optimal prescribing of statins and antihypertensives? A systematic umbrella review and evidence and gap map

OBJECTIVES

We aimed to map the systematic review evidence available to inform the optimal prescribing of statins and antihypertensive medication.

DESIGN

Systematic umbrella review and evidence and gap map (EGM).

DATA SOURCES

Eight bibliographic databases (Cochrane Database of Systematic Reviews, CINAHL, EMBASE, Health Management Information Consortium, MEDLINE ALL, PsycINFO, Conference Proceedings Citation Index-Science and Science Citation Index) were searched from 2010 to 11 August 2020. Update searches conducted in MEDLINE ALL 2 August 2022. We searched relevant websites and conducted backwards citation chasing.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We sought systematic reviews of quantitative or qualitative research where adults 16 years+ were currently receiving, or being considered for, a prescription of statin or antihypertensive medication. Eligibility criteria were applied to the title and abstract and full text of each article independently by two reviewers.

DATA EXTRACTION AND SYNTHESIS

Quality appraisal was completed by one reviewer and checked by a second. Review characteristics were tabulated and incorporated into an EGM based on a patient care pathway. Patients with lived experience provided feedback on our research questions and EGM.

RESULTS

Eighty reviews were included within the EGM. The highest quantity of evidence focused on evaluating interventions to promote patient adherence to antihypertensive medication. Key gaps included a lack of reviews synthesising evidence on experiences of specific interventions to promote patient adherence or improve prescribing practice. The evidence was predominantly of low quality, limiting confidence in the findings from individual reviews.

CONCLUSIONS

This EGM provides an interactive, accessible format for policy developers, service commissioners and clinicians to view the systematic review evidence available relevant to optimising the prescribing of statin and antihypertensive medication. To address the paucity of high-quality research, future reviews should be conducted and reported according to existing guidelines and address the evidence gaps identified above.

Mixed-methods research of motivational processes in workers' adoption of healthy behavior

BACKGROUND

In occupational health, the maintenance and promotion of workers' health, especially lifestyle motivation-based interventions, have gained considerable attention and are actively implemented. Motivational theories include self-determination theory, and some studies focus on healthy lifestyles. However, the effectiveness of health promotion interventions varies depending on the health awareness and motivation of the participants. Therefore, this study aimed to clarify the processes by which workers are motivated to improve their health and to identify the need for and type of support according to their motivation.

METHODS

Using a mixed-research design, an initial questionnaire survey of 94 employees (mean age = 40.97 ± 9.65) at a multicenter company in Japan, followed by semi-structured interviews with 16 employees (mean age = 40.13 ± 9.45) from the high- and low-motivation groups, were conducted. Multiple regression analysis followed by modified grounded theory-based analysis of the results of the first stage was used and the quantitative and qualitative results were integrated.

RESULTS

In the first stage, autonomous motivation scores were predicted by the behavioral change stage and relatedness satisfaction/frustration. The second stage revealed that "the process of reflecting and managing one's own health while receiving support and feedback for maintaining and improving health" was the motivational process of workers. Result integration revealed that motivation increased through repeatedly escaping and adjusting to real problems and situational coping until the behavioral change. Despite interruptions during behavioral change, receiving feedback from others could increase motivation and continued behavioral change.

CONCLUSION

Regardless of their level of motivation for health behaviors, workers indicated that support from others was essential. The nature of this support was found to range from providing information to offering feedback. Interventions individualized by the identified process could enable customized motivation-driven health guidance.

The Effect of a Group-Based Mindfulness and Acceptance Training on Psychological Flexibility and Adherence to Antiretroviral Therapy Among Adolescents in Uganda: An Open-Label Randomized Trial

Adherence to antiretroviral therapy (ART) is lower in adolescents with HIV (AWH) than in any other age group, partly due to self-regulatory challenges during development. Mindfulness and acceptance training have been shown to support psychological flexibility, a self-regulatory skill that potentially improves adolescent adherence to medication. We assessed the effect of weekly group-based mindfulness and acceptance training sessions on ART adherence among older adolescents (15-19 years) in Kampala, Uganda. One hundred and twenty-two AWH (median age 17, range 15-19 years, 57% female) receiving care at a public health facility in Kampala were randomized 1:1 to receive 4 weekly 90-min group sessions facilitated by experienced trainers or standard-of-care ART services. The training involved (Session 1) clarifying values, (Session 2) skillfully relating to thoughts, (Session 3) allowing and becoming aware of experiences non-judgmentally, and (Session 4) exploring life through trial and error. At baseline, postintervention, and 3-month follow-up, psychological flexibility was measured using the Avoidance and Fusion Questionnaire for Youth (AFQ-Y8), and self-reported ART adherence was assessed using the Morisky Medication Adherence Scale (MMAS-8). At baseline, the intervention and standard-of-care arms had similar psychological flexibility (AFQ-Y8 score:15.45 ± 0.82; 15.74 ± 0.84) and ART adherence (MMAS-8 score: 5.32 ± 0.24; 5.13 ± 0.23). Retention through the study was moderate (71%). Completion of mindfulness and acceptance training was associated with a significant reduction in psychological inflexibility at the 3-month follow-up (AFQ-Y8 score: 12.63 ± 1.06; 14.05 ± 1.07, P = .006). However, no significant differences were observed in self-reported adherence to ART at the 3-month follow-up (MMAS-8 score: 5.43 ± 0.23; 4.90 ± 0.33, P = .522). Group-based mindfulness and acceptance training improved psychological flexibility in this population of adolescents on ART in Uganda but did not significantly improve ART adherence. Future research should explore integrated approaches that combine behavioral management training with other empowerment aspects to improve ART adherence among AWH.

Can temporal self-regulation theory and its constructs predict medication adherence? A systematic review and meta-analysis

The relationships between temporal self-regulation theory (TST) constructs (intention, behavioural prepotency and self-regulatory capacity) and medication adherence should be established before further applying the theory to adherence. Searches of PsychINFO, Medline, EMBASE, CINAHL and Web of Science were conducted in 2019 (updated November 2021). Studies had to be original quantitative research, assessed the relationship between one of the constructs and adherence in one illness, and used an adult population. The risk of bias was assessed using the NHLBI Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Three meta-analyses were conducted using R. Moderation analyses were also conducted. A total of 57 articles (60 studies) with 13,995 participants were included, with 7 studies included in more than one analysis. Results identified significant correlations between intention (r = .369, [95% CI: .25, .48]), behavioural prepotency (r = .332, [95% CI: .18, .48]), self-regulatory capacity (r = .213, [95% CI: .10, .32]) and adherence. There was some evidence of publication bias and no significant moderators. No studies explored the interactions in the theory, so whilst the constructs adequately predict adherence, future research should apply the theory to adherence in a specific illness to assess these relationships. Pre-registered on Prospero: CRD42019141395.

Exploring Patients' Trust from a New Perspective. A Text-Analysis Study

The concept of trust has been extensively studied within the field of medicine. Yet, a list of factors that clearly influence patients' trust is still under debate. Moreover, the methodological approaches found in literature have been reported to be lacking in their assessments and measurements of trust relationships in the medical field although trust between a patient and medical provider has been proven to increase adherence and improve health outcomes. Hence, adding data to this debate and exploring a reliable method to explore the construct of trust is relevant. This study collects new evidence of the most salient indicators of patient trust by using a narrative approach and highlighting the potential of this method in collecting indicators that could be used to build training that aims to increase patients' trust. We used the Linguistic Inquiry and Word Count software for text analysis to examine the spontaneous narrations of episodes of trust and distrust within the doctor-patient relationship with a sample of 82 adult patients. Results demonstrate the role of the emotional aspects of the doctor-patient relationship. Data highlights the importance of doctors' benevolence toward patients, and positive emotions seem to be deeply connected with any experience of trust, which leads patients to feel more secure. Methods are presented to use these insights to construct mechanisms that establish medical trust and allow providers to implement effective interventions.

Preventing Heart Failure Readmission in Patients with Low Socioeconomic Position

PURPOSE OF REVIEW

This review aims to summarize the current burden of heart failure (HF) in the United States, specifically in patients with low socioeconomic position (SEP), and synthesize recommendations to prevent HF-related hospital readmissions in this vulnerable population.

RECENT FINDINGS

As treatments have improved, HF-related mortality has declined over time, resulting in more patients living with HF. This has led to an increase in hospitalizations, however, putting excess strain on our healthcare system. HF patients with low SEP are a particularly vulnerable group, as they experience higher rates of hospitalization and readmission compared to their high SEP counterparts. The Hospital Readmission Reduction Program (HRRP) was created to motivate interventions that reduce hospital readmissions across diseases, with HF being a primary target. Numerous readmission prevention efforts have been suggested to target the pre-hospitalization, hospitalization, and post-hospitalization phases, including addressing social determinants of health (SDoH), improving coordination of care, optimizing discharge plans, and improving adherence to follow-up care and medication regimens. Many of these proposed interventions show promise in reducing HF-related readmissions and issues surrounding adequate caregiver support may be particularly important to reduce readmissions among persons in low SEP. Reducing HF-related hospital readmissions is possible, even in vulnerable populations like those with low SEP, but this will require coordinated efforts across the healthcare system and throughout the life course of these patients. Caregiver support is a necessary part of optimized care for low SEP HF patients and future efforts should consider interventions that support these caregivers.

The Association Between Mild Cognitive Impairment and Medication Non-adherence Among Elderly Patients With Chronic Diseases

BACKGROUND

Medication adherence is essential for optimizing treatment outcomes in elderly patients who frequently contend with multiple chronic diseases requiring pharmacological interventions. Mild cognitive impairment (MCI) is a prevalent cognitive disorder among the elderly population, but its impact on medication adherence among elderly patients is still uncertain. This cross-sectional study aimed to investigate the impact of MCI on medication adherence among elderly patients.

METHODS

A cross-sectional study of 436 elderly patients with common chronic diseases aged 60 years and above was conducted. Medication adherence was measured using the Morisky Medication Adherence Scale-8 (MMAS-8). MCI was screened, and cognitive status was assessed using the Mini-Mental State Examination (MMSE) questionnaire. Multivariate logistic regression analysis was performed to identify independent risk factors of medication non-adherence.

RESULTS

Among these elderly patients, 212 (48.6%) had poor medication compliance, and 181 (41.5%) had MCI. Preliminary analyses showed a significant association between MCI and medication non-adherence among elderly patients (odds ratio (OR)=3.95, 95% confidence interval (95%CI)=2.63-5.92, P<0.001). Multivariate logistic regression analysis showed that MCI was independently associated with the risk of medication non-adherence among elderly patients (adjusted OR=2.64, 95%CI=1.64-4.24, P<0.001). Additionally, adverse drug reaction and poor evaluation of medication effects were also independently associated with medication non-adherence in elderly patients (P<0.05).

CONCLUSION

Findings from this cross-sectional study proved the substantial adverse impact of MCI on medication adherence among elderly patients, and MCI was an independently influential factor of medication non-adherence. Identifying the MCI status early and providing interventions to enhance medication adherence are undoubtedly essential for optimizing healthcare outcomes in elderly patients.

Medication Adherence Rates in Adolescents With Eosinophilic Esophagitis Are Low and Are Associated With Health Habits

Although swallowed topical steroids are effective in inducing histological remission in eosinophilic esophagitis (EoE), their efficacy is limited by treatment nonadherence. In this study, we objectively measured adherence rates to swallowed topical steroids in adolescents with EoE over the course of 8 weeks and analyzed the association between adherence rate, disease and demographic features, symptom severity, and medication-taking habit strength. We found that approximately 20% of adolescents with EoE were over-dosing on their medications. After excluding these patients, mean adherence rate was 67.0% (±19.4%) and median adherence rate was 63% (interquartile range 53%-88%). Adherence was not associated with demographic features, disease history, symptom severity, or quality of life but was associated with habit strength (Pearson r = 0.48, P = 0.04). These findings suggest that habit strength may serve as a potential target for interventions aimed at improving adherence in adolescents with EoE.

Self-administration of medications in inpatient postnatal women: an opportunity to empower self-care, improved medicines knowledge and adherence utilising clinical pharmacists and midwifery workforce and use of a midwife formulary

OBJECTIVES

To assess the impact of self-administration of medicines (facilitated by a midwife formulary) on postnatal women's knowledge of certain post-delivery medications, awareness of the Green Bag Scheme, factors contributing to constipation, pain satisfaction, adherence, and time released to midwives plus feedback from these women and their midwives.

METHODS

The study was conducted in consented postnatal women, who self-administered medications from their bedside lockers. The mode of delivery and parity were recorded. Data were compared in women who self-administered to those who did not. Midwives used our established midwife formulary to write their essential unprescribed medications. Direct interview questionnaires were used to obtain their knowledge on chosen post-delivery medicines, pain satisfaction, the Green Bag Scheme and factors contributing to constipation. Regular medicines counts were used to check adherence. Midwives' time not administering these self-administered medications was estimated. Self-reported questionnaires were used to obtain feedback from participants and midwives. Responses were analysed proportionately and where appropriate by simple statistics.

RESULTS

Women (n=203) who self-administered were compared with those (n=401) who did not. Greater medicines' knowledge and better (96% vs 79%) pain satisfaction were found in self-administering women. Knowledge of each contributing factor to constipation varied. Mode of delivery and parity had no impact on these outcomes. Adherence seemed high 96% (195/203). Awareness of the Green Bag Scheme was poor (66/604). Most women, 94% (191/203) found the service helpful and 89% (178/200) would take part again. At least 224 hours were released to midwives by these self-administering women. 164/203 (81%) midwives felt the scheme was beneficial.

CONCLUSIONS

Self-administering women had better pain satisfaction, medication knowledge and adherence. The need to improve engagement in the Green Bag Scheme was flagged. This service, supported by use of a midwife formulary, can release time to midwives to do other tasks including care for women with more complex issues. A business case for this service is under review.

Attendance-Based Adherence and Outcomes of Obesity Management Program in Arab Adolescents

Pediatric obesity has become a global pandemic in the last century, contributing to short and long-term medical conditions that heighten the risk of morbidity and mortality in children. The 12-month school-based obesity management educational program aims to assess the effect of adherence to the lifestyle educational program and target outcomes, obesity, and hypertension. A total of 363 (nonadherent, N = 179; adherent, N = 184) Saudi school adolescents aged 12-18 were recruited from 60 schools in Riyadh City, Saudi Arabia. Anthropometrics, lipid profile, and blood glucose were measured at baseline and post-intervention. The level of adherence was based on the number of attended educational sessions, and participants were grouped accordingly into two groups: adherent group (attended ≥ 3 sessions) and nonadherent group (attended 1-2 sessions) out of a total of five sessions. Results demonstrated that significantly more participants in the adherent group achieved the primary program goal of reducing obesity indices [body weight, body mass index (BMI), and BMI z-score] than the nonadherent group. Additionally, among adherent obese participants, BMI z-score significantly decreased after the 12-month intervention (post-intervention: 1.5 ± 0.7 vs. baseline: 1.7 ± 0.6, p < 0.05), while the trend in BMI z-score modestly increased in the nonadherent obese participants post-intervention (post-intervention: 1.8 ± 0.7 vs. baseline: 1.7 ± 0.6, p > 0.05). Moreover, there was a substantial reduction in hypertension prevalence only in the adherent group (p = 0.003) and among adherent obese participants in particular (p = 0.03). Furthermore, adherence to session attendance was higher in girls than boys, which led to better outcomes among girls than boys. For the secondary outcomes, lipid profile indices increased in both groups, while no changes were observed in the glycemic profile. In conclusion, greater adherence to educational sessions achieved modest but favorable weight changes and improved blood pressure among obese adolescents. Future intervention studies should take into consideration the need to improve attendance to enhance adherence to the program among adolescents at risk.

Medication nonadherence: health impact, prevalence, correlates and interventions

Nonadherence to medicines is a global problem compromising health and economic outcomes for individuals and society. This article outlines how adherence is defined and measured, and examines the impact, prevalence and determinants of nonadherence. It also discusses how a psychosocial perspective can inform the development of interventions to optimise adherence and presents a series of recommendations for future research to overcome common limitations associated with the medication nonadherence literature. Nonadherence is best understood in terms of the interactions between an individual and a specific disease/treatment, within a social and environmental context. Adherence is a product of motivation and ability. Motivation comprises conscious decision-making processes but also from more 'instinctive', intuitive and habitual processes. Ability comprises the physical and psychological skills needed to adhere. Both motivation and ability are influenced by environmental and social factors which influence the opportunity to adhere as well as triggers or cues to actions which may be internal (e.g. experiencing symptoms) or external (e.g. receiving a reminder). Systematic reviews of adherence interventions show that effective solutions are elusive, partly because few have a strong theoretical basis. Adherence support targeted at the level of individuals will be more effective if it is tailored to address the specific perceptions (e.g. beliefs about illness and treatment) and practicalities (e.g. capability and resources) influencing individuals' motivation and ability to adhere.

Economic evaluation of interventions to improve medication adherence among patients with chronic diseases: an overview of systematic reviews

INTRODUCTION

This overview aimed to find, assess, and synthesize systematic reviews that compared the cost-effectiveness of interventions designed to improve medication adherence among patients with chronic disease.

AREAS COVERED

PubMed, Web of Science, Cochrane Database of Systematic Reviews, and Center for Review and Dissemination were searched. The quality of the included reviews was assessed using two validated checklists. The review characteristics and findings were summarized narratively. A total of 9 systematic reviews were included. Interventions reported to be cost-effective were simplification of the medication regimen, financial incentives, improved coverage or reduced out-of-pocket spending, and pharmacist care. The most common interventions were patient education and counseling, with mixed results of cost-effectiveness. This evidence comes from economic evaluations with varying degrees of quality.

EXPERT OPINION

Future evaluations of adherence interventions' cost-effectiveness will be improved in quality as our understanding of the reasons behind intentional and unintentional nonadherence and factors associated with this behavior advances. The development of criteria for the value assessment of medication adherence-enhancing interventions will contribute to improving the quality of adherence intervention cost-effectiveness research.

Managing Medications and Medication Adherence Among US Adults During the Early Phase of the COVID-19 Pandemic

PURPOSE

Before the COVID-19 pandemic and the disruptions it brought, medication adherence was already a challenging and complex health behavior. The purpose of this study was to describe patients' interactions in clinic, pharmacy, and home contexts and associated medication management and adherence during the early phase of the COVID-19 pandemic.

PATIENTS AND METHODS

A survey questionnaire was developed using the Medication Adherence Context and Outcomes framework and distributed via social media between May and July 2020 targeting adults taking a daily prescribed medication. Survey questions assessed sociodemographics, interactions with healthcare providers, clinics, pharmacies, medication management experiences, habit strength, and life chaos perceptions during the pandemic. Medication adherence was assessed by the self-report BAASIS© scale to measure implementation, discontinuation, and overall nonadherence.

RESULTS

A total of 134 adults from the United States, mean age 50.0 (SD 16.1) years were included in this analysis. Respondents took a median of 3.50 (interquartile range 4) daily medications. Delays in seeing a provider were reported by 47 (35.1%). Pharmacy encounters were impacted; 25 (18.7%) indicated their method for obtaining medication changed. Medication nonadherence was reported among 62 (46.3%) and was significantly greater among those who delayed prescription refills (p=0.032), pillbox users (p=0.047), and those who experienced greater life chaos (p=0.040) and lower habit strength (p<0.001) in the early phase of the pandemic.

CONCLUSION

Although the early phase of the pandemic affected access to care for nearly one-third of the sample, distance-accessible care options and strategies to obtain needed services without being in-person supported respondents medication management. Helpful strategies included provider accessibility, telehealth, home delivery/mail-order, drive-thru's, 90-day supplies, and online/automatic refills. Methods to develop and reestablish habits are critical. Care providers in clinic and pharmacy settings can educate and remind patients about services like distance-accessible technologies and online ordering of medications and establishing routines to support medication adherence.

Supporting adjuvant endocrine therapy adherence in women with breast cancer: the development of a complex behavioural intervention using Intervention Mapping guided by the Multiphase Optimisation Strategy

BACKGROUND

Adjuvant endocrine therapy (AET) reduces the risk of breast cancer recurrence and mortality. However, up to three-quarters of women with breast cancer do not take AET as prescribed. Existing interventions to support adherence to AET have largely been unsuccessful, and have not focused on the most salient barriers to adherence. This paper describes the process of developing four theory-based intervention components to support adherence to AET. Our aim is to provide an exemplar of intervention development using Intervention Mapping (IM) with guidance from the Multiphase Optimisation Strategy (MOST).

METHODS

Iterative development followed the six-stage IM framework with stakeholder involvement. Stage 1 involved a literature review of barriers to adherence and existing interventions, which informed the intervention objectives outlined in Stage 2. Stage 3 identified relevant theoretical considerations and practical strategies for supporting adherence. Stage 4 used information from Stages 1-3 to develop the intervention components. Stages 1-4 informed a conceptual model for the intervention package. Stages 5 and 6 detailed implementation considerations and evaluation plans for the intervention package, respectively.

RESULTS

The final intervention package comprised four individual intervention components: Short Message Service to encourage habitual behaviours surrounding medication taking; an information leaflet to target unhelpful beliefs about AET; remotely delivered Acceptance and Commitment Therapy-based guided self-help to reduce psychological distress; and a website to support self-management of AET side-effects. Considerations for implementation within the NHS, including cost, timing and mode of delivery were outlined, with explanation as to how using MOST can aid this. We detail our plans for the final stage of IM which involve feasibility testing. This involved planning an external exploratory pilot trial using a 24-1 fractional factorial design, and a process evaluation to assess acceptability and fidelity of intervention components.

CONCLUSIONS

We have described a systematic and logical approach for developing a theoretically informed intervention package to support medication adherence in women with breast cancer using AET. Further research to optimise the intervention package, guided by MOST, has the potential to lead to more effective, efficient and scalable interventions.

Advancing behavioral interventions for African American/Black and Latino persons living with HIV using a new conceptual model that integrates critical race theory, harm reduction, and self-determination theory: a qualitative exploratory study

BACKGROUND

Rates of participation in HIV care, medication uptake, and viral suppression are improving among persons living with HIV (PLWH) in the United States. Yet, disparities among African American/Black and Latino PLWH are persistent, signaling the need for new conceptual approaches. To address gaps in services and research (e.g., insufficient attention to structural/systemic factors, inadequate harm reduction services and autonomy support) and improve behavioral interventions, we integrated critical race theory, harm reduction, and self-determination theory into a new conceptual model, then used the model to develop a set of six intervention components which were tested in a larger study. The present qualitative study explores participants' perspectives on the study's acceptability, feasibility, and impact, and the conceptual model's contribution to these experiences.

METHODS

Participants in the larger study were African American/Black and Latino PLWH poorly engaged in HIV care and with non-suppressed HIV viral load in New York City (N = 512). We randomly selected N = 46 for in-depth semi-structured interviews on their experiences with and perspectives on the study. Interviews were audio-recorded and professionally transcribed verbatim, and data were analyzed using directed qualitative content analysis.

RESULTS

On average, participants were 49 years old (SD = 9) and had lived with HIV for 19 years (SD = 7). Most were male (78%) and African American/Black (76%). All had taken HIV medication previously. Challenging life contexts were the norm, including poverty, poor quality/unstable housing, trauma histories exacerbated by current trauma, health comorbidities, and substance use. Participants found the study highly acceptable. We organized results into four themes focused on participants' experiences of: 1) being understood as a whole person and in their structural/systemic context; 2) trustworthiness and trust; 3) opportunities for self-reflection; and 4) support of personal autonomy. The salience of nonjudgment was prominent in each theme. Themes reflected grounding in the conceptual model. Participants reported these characteristics were lacking in HIV care settings.

CONCLUSIONS

The new conceptual model emphasizes the salience of systemic/structural and social factors that drive health behavior and the resultant interventions foster trust, self-reflection, engagement, and behavior change. The model has potential to enhance intervention acceptability, feasibility, and effectiveness with African American/Black and Latino PLWH.

A Systematic Review and Meta-analysis of Face-to-face Medication Adherence Interventions for Patients with Long Term Health Conditions

BACKGROUND

Although previous reviews demonstrated effectiveness related to medication adherence interventions, they incorporated various digital platforms and other multiple delivery modes, which makes difficult to distinguish what aspects of the interventions led to effectiveness.

PURPOSE

This review aimed to (i) estimate the efficacy of face-to-face medication adherence interventions on adherence outcomes, in adults with Long Term Health Conditions (LTHCs) and (ii) identify the Behaviour Change Techniques (BCTs) used in the interventions and examine their potential impact on efficacy.

METHODS

Cochrane Controlled Register of Trials, Embase, MEDLINE (Ovid), PsycINFO, Web of Science, PubMed, and Scopus databases were searched. Randomized controlled trials were included if they described an intervention to improve medication adherence, delivered via face-to-face only, and included patients with LTHCs. Studies were excluded if they used additional delivery modes, involved family members or used a group format. In addition, use of BCTs was coded.

RESULTS

20 studies were included (n = 3667). Statistically significant pooled effects were found favoring the intervention than control, for the following MEMS (electronic monitoring) measures: percentage of prescribed doses taken on time over a period of 3 weeks to 2 months (MD 9.34, 95% CI 4.36-14.33, p = .0002; I2 =0%); percentage of prescribed doses taken for a period of 1 week to 2 months (MD 5.63, 95% CI 1.62-9.64, p = .006; I2 = 51%) and for 1 month (OR = 2.51, 95% CI 1.37-4.57, p = .003; I2 = 0%); percentage of days correct doses taken for 1 month to 14 weeks (MD 6.59, 95% CI 0.74-13.15, p = .03; I2 = 68%). Studies using the Morisky scale showed a significant between group difference for 1-3 months (MD 0.86, 95% CI 0.59-1.13, p < .00001; I2 = 0%). Overall, more BCTs were identified in intervention conditions than in comparison conditions (22 vs. 10). The impact of BCTs on intervention effectiveness could not be established as the analyses were underpowered.

CONCLUSIONS

Face-to-face interventions increased adherence to medication among adult patients with LTHCs. Although we were able to identify BCTs among interventions, data were insufficient to determine the impact of particular BCTs on intervention effectiveness.

Mental Health Care Provider's Perspectives Toward Adopting a Novel Technology to Improve Medication Adherence

Objective

To understand perspectives of mental health care providers regarding barriers and drivers of adopting a medication ingestible event monitoring (IEM) system in clinical practice.

Methods

Between April and October 2019, a cross‐sectional, online survey was conducted among 131 prescribing clinicians and 119 non‐prescribing clinicians providing care to patients with major depressive disorder, bipolar disorder, and schizophrenia.

Results

Most prescribing clinicians were physicians (79.4%) while most non‐prescribing clinicians (52.9%) were licensed clinical social workers, followed by counselors (30.8%), clinical psychologists (13.4%), and case managers (2.5%). Most respondents (93.2%) reported that clinicians can influence adherence, that the IEM technology was in their patients' best interest (63.6%), and a willingness to beta test the technology (54.8%). Support was positively associated with prescribing clinicians (OR: 2.2; 95% CI: 1.1, 4.5), belief that antipsychotics reduce the health, social, or financial consequences of the condition (OR: 3.8; 95% CI: 1.3, 11.0), concern for patients' well‐being without monitoring (OR: 3.3; 95% CI: 1.2, 8.7), and belief the technology will enhance clinical alliance (OR: 3.1; 95% CI: 1.5, 6.3) or improve patient engagement (OR: 3.0; 95% CI: 1.5, 6.2). Support was inversely related to concerns about appropriate follow‐up actions (OR: 0.4; 95% CI: 0.2, 0.9) and responsibilities (OR: 0.3; 95% CI: 0.1, 0.8) when using the technology.

Conclusions

Our results suggest that IEM sensor technology adoption will depend upon additional evidence that patients will actively engage in the use of the technology, will benefit from the technology through improved outcomes, and that the additional burden placed upon providers is minimal compared to the potential benefit.

Among clinicians with prescribing authority, 91.6% are concerned about the quality of self‐reported medication adherence and 75.6% reported that the IEM sensor technology would be in their patients' “best interest”.

Most prescribing (85.5%) and non‐prescribing (74.0%) clinicians believe that the IEM sensor technology will either improve patient outcomes or practice efficiency.

A key barrier to adoption appears to be concern about how to incorporate these data into practice.

'Improving smart medication management': an online expert discussion

Medication safety continues to be a problem inside and outside the hospital, partly because new smart technologies can cause new drug-related challenges to prescribers and patients. Better integrated digital and information technology (IT) systems, improved education on prescribing for prescribers and greater patient-centred care that empowers patients to take control of their medications are all vital to safer and more effective prescribing. In July 2021, a roundtable discussion was held as a spin-off meeting of the International Forum on Quality and Safety in Health Care Europe 2021 to discuss challenges and future direction in smart medication management. This manuscript summarises the discussion focusing on the aspects of digital and IT systems, safe prescribing, improved communication and education, and drug adherence.

A conceptual model of alcohol use and adherence to antiretroviral therapy: systematic review and theoretical implications for mechanisms of action

Alcohol consumption is one of the most prevalent correlates of antiretroviral therapy (ART) adherence, yet causal processes underlying this association remain largely unexplored. The goal of this systematic review was to develop a conceptual model that describes the causal effect of alcohol consumption on ART nonadherence. We reviewed 230 studies that examined the association between alcohol consumption and ART adherence with three primary aims: (1) to replicate and extend previous reviews of the literature, (2) to summarize and critique study designs capable of answering questions about temporal overlap and (3) to summarize potential mechanisms of action. A model of alcohol-associated ART nonadherence was proposed to guide future work, integrating general theories of ART adherence and theory on the psychological and behavioral effects of alcohol intoxication. The conceptual model describes two mechanistic processes-prospective memory impairment and interactive toxicity beliefs/avoidance behaviors-involved in alcohol-associated intentional and unintentional nonadherence, respectively. This model can be used to guide future research on the causal processes involved in the frequently observed correlation between alcohol consumption and adherence.

Women's Reports of Barriers to and Facilitators of Oral Medication Adherence During Ovarian Stimulation: A Mixed Methods Pilot Study

Background:

Adherence to lifestyle modification recommendations remains problematic for women undergoing fertility treatment, raising concerns about the extent to which women adhere to prescribed medication regimens. Limited data have shown suboptimal oral medication adherence rates of 19% to 74%. The objective of this study was to explore what women perceive as barriers to and facilitators of oral medication adherence during fertility treatment cycles.

Methods:

An exploratory mixed methods pilot study was conducted among a sample of 30 women who were actively taking one to two cycles of letrozole or clomiphene citrate for ovarian stimulation in conjunction with intrauterine insemination cycles. Medication adherence barriers were measured using a 20-item survey. Medication adherence facilitators and personal experiences with fertility treatment were assessed with structured interviews. Medication adherence was assessed with electronic event monitoring.

Results:

The overall medication adherence median was 0.97 with a range of 0.75 to 1.00, and nine women (50%) demonstrated perfect adherence. The most commonly reported barriers were recently feeling sad, down, or blue (53%), and taking medication more than once per day (40%). Women with higher barrier scores had significantly lower medication adherence scores (p=0.02) compared to women with lower total barrier scores. Facilitators included using physical aides as reminders (60%) and establishing a daily routine (50%). No significant correlation was found between medication adherence scores and facilitators.

Conclusion:

The dynamic interplay between perceived barriers and facilitators and women’s medication-taking patterns could influence whether or not medication regimens are followed correctly.

Why do patients struggle with their medicines?-A phenomenological hermeneutical study of how patients experience medicines in their everyday lives

Why do so many people struggle with their medicines despite decades of research on medicines taking? Research into how people experience medicines in their everyday life remains scarce with the majority of research in this area of focusing on whether or not people take their medicines as prescribed. Hence, this study used a phenomenological hermeneutical qualitative design to gain a deeper understanding of individuals’ perspectives on the lived experience of medicine-taking. Findings from this study highlight five main themes where participants experience medicines as: 1) life-saving and indispensable, 2) normal and a daily routine, 3) confusing and concerning, 4) unsuitable without adjustment, and 5) intrusive and unwelcome. These results can be the basis for mutually agreed prescribing through a co-creative approach that aims at enhancing open and honest dialogues between patients and healthcare professionals in partnership about medicines.

Impact of a mobile phone app on adherence to treatment regimens among hypertensive patients: A randomised clinical trial study

BACKGROUND

Hypertension is one of the most prevalent long-term diseases seen in many countries, including Palestine. Patients with poorly controlled blood pressure are more likely to develop several complications. Therefore; it is imperative to control their blood pressure by improving their adherence to the treatment regimen.

AIM

The objective of this study was to evaluate the impact of using a mobile phone app on the level of adherence to treatment regimens among hypertensive patients in the Gaza Strip.

METHODS AND RESULTS

This study used an experimental design with a pre and post-intervention assessment. Using the Hill-Bone compliance to high blood pressure therapy scale, 191 participants completed the study: 94 in the control group and 97 in the intervention group. The intervention group used a phone app which reminds participants to take their medication, reminding them about their follow-up appointments and sending educational information about hypertension management. After 3 months of intervention, the level of adherence to treatment was reassessed. Results showed that participants in both groups showed a significant improvement in adherence levels, with higher improvements in the intervention group in the total score as well as all three domain scores: adherence to medication, diet and keeping appointments.

CONCLUSION

The use of a mobile phone app resulted in improvements in adherence to hypertension treatment. Thus, this study confirms the potential effectiveness of mobile technology in improving treatment adherence in hypertension and an opportunity to reduce cardiovascular mortality and morbidity. However, wider adoption has to be accompanied by ongoing evaluation and integration in public health systems.

Treatment Adherence in Integrative Medicine-Part One: Review of Literature

Treatment adherence is a topic that is well studied but not well understood. Low treatment adherence is a significant issue that limits the effective management and treatment of chronic conditions, creating significant health care burden, costs, and poor patient outcomes. This report provides a review of the factors that facilitate or create barriers to treatment adherence, as well as strategies recommended to overcome adherence barriers. A total of 25 interviews were conducted with practitioners demonstrating both high (n = 16) and low (n = 9) treatment adherence rates. A total of 185 survey responses were received from high-treatment adherence rate practitioners (n = 21), low-treatment adherence rate practitioners (n = 83), and practitioners that were neither in the high- or low-treatment adherence rate range (n = 81). Practitioner prescribing behaviors and adherence statistics were determined and stratified by high-treatment adherence rate and low-treatment adherence rate practitioners. From the interviews, 78% of low-rate practitioners mentioned that establishing trust is a primary best practice for optimizing adherence, and for high-rate practitioners, 69% thought that facilitating trust was important to optimizing adherence. Both low- and high-adherence rate practitioners prioritized using a staged approach as a strategy to overcome barriers to adherence. From the total survey sample it was found that key strategies to improving adherence included the practice of booking follow-up appointments, using lab results to explain treatment plans, and using a staged approach for treatment plans. Our research sought to elicit strategies and skills that can help improve treatment adherence in integrative medicine and our findings have identified several common practices that can help to improve adherence. Research taking advantage of mobile devices and the internet for adherence has started to expand within the last 10 to 15 years. Technology has the potential to lead the development and establishment of a centralized database that acquires adherence information and provides solutions to its practitioners and patients. Further work to advance the field of integrative medicine through additional research and interventions that support treatment adherence would be valuable to the effective treatment and management of integrative medicine patients.

Can an individualized adherence education program delivered by nurses improve therapeutic adherence in elderly people with acute myocardial infarction?: A randomized controlled study

BACKGROUND

The ageing of the population is leading to an increase in the number of elderly patients with acute myocardial infarction. These patients are at higher risk for complications and poor medication adherence, which in turn are associated with higher healthcare resource expenditures. Nursing programmes might help to improve adherence in these complex patients.

OBJECTIVE

The objective of this study was to assess the impact of a nursing intervention on therapeutic adherence in elderly patients after myocardial infarction compared to a control group.

DESIGN

A single-blind, randomized controlled trial.

SETTINGS

Heart disease institute of a tertiary care hospital.

PARTICIPANTS

Patients aged ≥75 years with myocardial infarction undergoing percutaneous coronary intervention.

METHODS

A comprehensive geriatric assessment was performed during the admission in all patients (N=143). Patients were randomly allocated to a nursing intervention group (n=68) or a usual care group (n=75). In patients from the intervention group, a nursing intervention programme was performed 3 months after admission based on education support and patient monitoring to improve therapeutic adherence. The main outcome measured was 12-months therapeutic adherence, as defined by a combination of measurement tools (Morisky-Green and Hayness-Sacket scales, attendance at visits and withdrawal of medication from the pharmacy). Therapeutic adherence was assessed by nurses blinded to the assignment group.

RESULTS

The mean age was 82.2 years. The proportion of comorbidities was significant (diabetes mellitus 51/143 (35.7%), hypertension 110/143 (76.9%), prior stroke 22/143 (15.4%)). Likewise, the proportion of geriatric syndromes was noticeable (frailty 26/143 (18.2%), risk of malnutrition 38/143 (26.6%), cognitive impairment 28/143 (19.6%)). Most patients (92.3%) had a low educational level. A total of 119 patients achieved 12-month assessment adherence. Among these patients, the proportions of adherence were as follows: Morisky-Green test: 76/119 (63.9%), Haynes-Sackett test 99/119 (83.2%), medical visits compliance 95/119 (79.8%), and correct acquisition of drugs in the pharmacy 74/119 (62.2%). A total of 42/119 patients (35.3%) were adherent as defined by the combination of the 4 measures. Therapeutic adherence at 12 months was achieved in a significantly higher proportion of patients from the nursing intervention group (51.9% vs 21.5%, p<0.001).

CONCLUSION

A significant proportion of elderly patients with myocardial infarction were non-adherent at 12 months. The proportion of adherent patients was highly variable according to the different tools used. A structured nursing intervention was independently associated with a higher adherence rate, as assessed by a multidimensional measurement, in this subset of complex high-risk elderly patients with myocardial infarction.

TRIAL REGISTRATION

Registered with www.clinicaltrials.gov (NCT04662762).

Association between reported medication adherence and health-related quality of life in adult patients with haemophilia

Background Medication adherence is an important issue, not just health-related, for patients with haemophilia. Poor medication adherence to long-term therapies limits the potential of effective treatments to improve patients' health-related quality of life. Objective The aim of this study was to investigate the association of reported medication adherence and health-related quality of life in patients with haemophilia. Setting Data were collected from patients at University Hospital Centre Zagreb, Croatia and at University Medical Centre Ljubljana, Slovenia. Method Adult male patients with severe or moderate haemophilia receiving prophylactic treatment were eligible for the study. Main outcome measure Implementation phase of medication adherence was assessed with the self-reported VERITAS-Pro instrument and health-related quality of life with SF-36v2. Results A total of 82 participants were included in the study (median age was 44.50, range 18-73 years). The majority of our participants reported being adherent to medication (83%). Participants showed better health in the mental health domains and Mental Component Summary than in the physical health domains and Physical Component Summary. After controlling for demographic, socioeconomic and clinical predictors, better reported medication adherence explained an additional 4-6% of better health variance in Bodily Pain and Social Functioning domains and Mental Component Summary. Conclusion We found that reported medication adherence can contribute to better health-related quality of life in patients with haemophilia. Since life with a chronic condition is demanding, it is an important finding that medication adherence to replacement therapy can improve life conditions for patients with haemophilia.

A Web-Based eHealth Intervention to Improve the Quality of Life of Older Adults With Multiple Chronic Conditions: Protocol for a Randomized Controlled Trial

Background

Multiple chronic conditions (MCCs) are common among older adults and expensive to manage. Two-thirds of Medicare beneficiaries have multiple conditions (eg, diabetes and osteoarthritis) and account for more than 90% of Medicare spending. Patients with MCCs also experience lower quality of life and worse medical and psychiatric outcomes than patients without MCCs. In primary care settings, where MCCs are generally treated, care often focuses on laboratory results and medication management, and not quality of life, due in part to time constraints. eHealth systems, which have been shown to improve multiple outcomes, may be able to fill the gap, supplementing primary care and improving these patients’ lives.

Objective

This study aims to assess the effects of ElderTree (ET), an eHealth intervention for older adults with MCCs, on quality of life and related measures.

Methods

In this unblinded study, 346 adults aged 65 years and older with at least 3 of 5 targeted high-risk chronic conditions (hypertension, hyperlipidemia, diabetes, osteoarthritis, and BMI ≥30 kg/m2) were recruited from primary care clinics and randomized in a ratio of 1:1 to one of 2 conditions: usual care (UC) plus laptop computer, internet service, and ET or a control consisting of UC plus laptop and internet but no ET. Patients with ET have access for 12 months and will be followed up for an additional 6 months, for a total of 18 months. The primary outcomes of this study are the differences between the 2 groups with regard to measures of quality of life, psychological well-being, and loneliness. The secondary outcomes are between-group differences in laboratory scores, falls, symptom distress, medication adherence, and crisis and long-term health care use. We will also examine the mediators and moderators of the effects of ET. At baseline and months 6, 12, and 18, patients complete written surveys comprising validated scales selected for good psychometric properties with similar populations; laboratory data are collected from eHealth records; health care use and chronic conditions are collected from health records and patient surveys; and ET use data are collected continuously in system logs. We will use general linear models and linear mixed models to evaluate primary and secondary outcomes over time, with treatment condition as a between-subjects factor. Separate analyses will be conducted for outcomes that are noncontinuous or not correlated with other outcomes.

Results

Recruitment was conducted from January 2018 to December 2019, and 346 participants were recruited. The intervention period will end in June 2021.

Conclusions

With self-management and motivational strategies, health tracking, educational tools, and peer community and support, ET may help improve outcomes for patients coping with ongoing, complex MCCs. In addition, it may relieve some stress on the primary care system, with potential cost implications.

Trial Registration

ClinicalTrials.gov NCT03387735; https://www.clinicaltrials.gov/ct2/show/NCT03387735.

International Registered Report Identifier (IRRID)

DERR1-10.2196/25175

Home Care Patients' Experiences with Home Care Nurses' Support in Medication Adherence

PURPOSE

To describe nurses' support interventions for medication adherence, and patients' experiences and desired improvements with this care.

PATIENTS AND METHODS

A two-phase study was performed, including an analysis of questionnaire data and conducted interviews with members of the care panel of the Netherlands Patients Federation. The questionnaire assessed 14 types of interventions, satisfaction (score 0-10) with received interventions, needs, experiences, and desired improvements in nurses' support. Interviews further explored experiences and improvements. Data were analyzed using descriptive statistics and a thematic analysis approach.

RESULTS

Fifty-nine participants completed the questionnaire, and 14 of the 59 participants were interviewed. The satisfaction score for interventions was 7.9 (IQR 7-9). The most common interventions were: "noticing when I don't take medication as prescribed" (n = 35), "helping me to find solutions to overcome problems with using medications" (n = 32), "helping me with taking medication" (n = 32), and "explaining the importance of taking medication at the right moment" (n = 32). Fifteen participants missed ≥1 of the 14 interventions. Most mentioned the following: "regularly asking about potential problems with medication use" (33%), "regularly discussing whether using medication is going well" (29%), and "explaining the importance of taking medication at the right moment" (27%). Twenty-two participants experienced the following as positive: improved self-management of adequate medication taking, a professional patient-nurse relationship to discuss adherence problems, and nurses' proactive attitude to arrange practical support for medication use. Thirteen patients experienced the following as negative: insufficient timing of home visits, rushed appearance of nurses, and insufficient expertise about side effects and taking medication. Suggested improvements included performing home visits on time, more time for providing support in medication use, and more expertise about side effects and administering medication.

CONCLUSION

Overall, participants were satisfied, and few participants wanted more interventions. Nurses' support improved participants' self-management of medication taking and enabled patients to discuss their adherence problems. Adequately timed home visits, more time for support, and accurate medication-related knowledge are desired.

A Qualitative Application of Temporal Self-Regulation Theory to Understand Adherence to Simple and Complex Medication Regimens

Medication adherence is a global health concern, and variables of temporal self-regulation theory (TST) have been shown to be important in improving adherence. This qualitative study aims to explore how TST can help explain medication adherence in people’s daily lives, and whether there are differences in the adherence to simple and complex medication regimens. Twenty-nine participants from Australia engaged in semi-structured interviews based on TST (intention, behavioural prepotency, self-regulation), and other variables important to adherence. Interviews were analysed using thematic analysis. Six themes were identified (Routines, External Supports, Cost, Sense of Agency, Adverse Outcomes, and Weighing Up Pros and Cons), with partial support for TST (specifically intention, past behaviour, cues and planning). Four themes not related to TST were also identified. Individuals with more complex medication regimens spoke of the importance of routines, planning, and knowledge-seeking, whereas those with simpler regimens spoke of the importance of visual cues. TST may be useful for identifying some variables important in medication adherence, however, additional factors were also identified. For simple regimens, future research should focus on the manipulation of visual cues. For complex regimens, health professionals should consider supporting the use of medication management apps to assist in planning and ensuring a consistent routine.

Interventions to improve medication adherence in mental health: the update of a systematic review of cost-effectiveness

OBJECTIVE

Medication non-adherence in mental health problems has social and economic costs. The objective of the study was to review the cost-effectiveness of interventions to enhance medication adherence in patients with mental health problems.

METHODS

The update of a previous systematic review was performed. Databases were searched in June 2019: MEDLINE, PSYCINFO, EMBASE, CINAHL, CRD, WOS. Cost-effectiveness studies comparing an intervention to improve the medication adherence with other interventions/usual care in adults with mental health problems were included. Data were extracted, methodological quality of the studies was assessed and a narrative synthesis was performed.

RESULTS

Nine studies were included in the review. The interventions that showed medication adherence increase were: a financial incentive when depot injection was taken by patients with psychotic disorders, a value-based benefit design policy including copayment and counselling in a company setting, and a medication treatment decision supported by a pharmacogenetic test. The other studies (coaching by pharmacists; a psychological and educational intervention at health care centres) did not find differences between groups. No study found cost differences between alternatives.

CONCLUSIONS

Interventions to improve medication adherence in adults with mental health problems could be cost-effective, especially those based on financial incentives, although more research is needed. KEYPOINTS There are several types of interventions designed to enhance medication adherence in patients with mental health problems. Few of them have demonstrated cost-effectiveness. Two studies found that a financial incentive per depot injection in patients with psychotic disorders improved the medication adherence. Two other studies found improvement in adherence due to two specific interventions: a value-based benefit design policy in a company setting and a pharmacogenetic test supporting the medication treatment decision. No study found differences in costs between the intervention and the comparator. More research is needed to implement cost-effective interventions.

What is the Impact of Outreach Services on Medication Adherence for COPD Patients? A Systematic Review

Chronic obstructive pulmonary disease (COPD) patients have been known to have poor medication adherence rates. The purpose of this systematic review was to assess if outreach services could impact on medication compliance rates. CINAHL, Medline, Clinical Key and Cochrane library were all searched electronically along with grey literature for all eligible studies conducted on COPD patients in a non-acute hospital setting. Systematic review methodology was followed for data selection, extraction and risk of bias, validity testing and data analysis. Eight studies met all inclusion criteria. 4 randomised control trials and 4 quantitative intention-to-treat studies. 2 of the studies failed validity testing but due to a lack of articles, were included in the synthesis. Given the heterogeneity of data, a narrative synthesis was adopted. All 8 studies demonstrated the ability for an outreach service to improve medication adherence in the community setting. Secondary to this result, this systematic review showed the ability to reduce hospital admissions of exacerbations of COPD due to increased medication adherence. Quality of life was assessed but did not improve but importantly did not decrease. Medication adherence has the potential to be improved from an outreach programme but requires more high-quality research in the area to develop a standardised plan of care to identify the most effective way of educating patients on medication adherence. Medication adherence education should not be a once-off assessment, this systematic review has shown it must be continuous, re-checked and re-educated regularly.

Assessing Barriers to and Level of Adherence to Hypertension Therapy among Palestinians Living in the Gaza Strip: A Chance for Policy Innovation

Introduction

Hypertension is a major health concern, especially in low-income countries. Nonadherence and poor or no persistence in adhering to hypertension treatment regimens result in uncontrolled high blood pressure, increasing rates of mortality and morbidity, and preventable healthcare costs. The aim of this study was to assess the level of adherence and barriers to treatment regimens among hypertensive patients living in the Gaza Strip, Palestine.

Methods

A convenience sample of 648 participants completed the Hill-Bone Compliance to High Blood Pressure Therapy Scale. The great majority of participants (n = 521, 80.4%) was highly adherent to their treatment regimen, 123 participants (18.98%) were classified as moderately nonadherent, and 4 (0.62%) participants were classified as highly nonadherent to their hypertension treatment regimen. Participants of this study showed the highest adherence rate to the domain of medication adherence (mean of 1.42 out of 4) followed by appointment keeping (mean 1.8), while they were least adherent to diet (mean of 2.18). The greatest three barriers to adherence to the recommended treatment regimen reported by participants were inability to exercise, inability to resist fast and fried food, and inability to keep themselves away from salty foods.

Conclusion

Overall adherence to medication in Gaza was surprisingly good in patients with a diagnosis of hypertension for at least one year. However, adherence to lifestyle advice or dietary regimes remains poor. A combination of interventions using low-cost mobile technology, combined with face-to-face interventions by healthcare professionals, can be applied to improve adherence to hypertension treatment regimens in order to reduce the consequences of uncontrolled blood pressure.

A systematic overview of systematic reviews evaluating medication adherence interventions

PURPOSE

To systematically summarize evidence from multiple systematic reviews (SRs) examining interventions addressing medication nonadherence and to discern differences in effectiveness by intervention, patient, and study characteristics.

SUMMARY

MEDLINE, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects were searched for papers published from January 2004 to February 2017. English-language SRs examining benefits of medication adherence interventions were eligible. Inclusion was limited to adult patients prescribed medication for 1 of the following disease conditions: diabetes and prediabetes, heart conditions, hypertension and prehypertension, stroke, and cognitive impairment. Non-disease-specific SRs that considered medication adherence interventions for older adults, adults with chronic illness, and adults with known medication adherence problems were also included. Two researchers independently screened titles, abstracts, and full-text articles. They then extracted key variables from eligible SRs, reconciling discrepancies via discussion. A MeaSurement Tool to Assess systematic Reviews (AMSTAR) was used to assess SRs; those with scores below 8 were excluded. Conclusions regarding intervention effectiveness were extracted. Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology was applied to assess evidence quality.

RESULTS

Of 390 SRs, 25 met the inclusion criteria and assessed adherence as a primary outcome. Intervention types most consistently found to be effective were dose simplification, patient education, electronic reminders to patients, and reduced patient cost sharing or incentives. Of 50 conclusions drawn by the SRs, the underlying evidence was low or very low quality for 45 SRs.

CONCLUSION

Despite an abundance of primary studies and despite only examining high-quality SRs, the vast majority of primary studies supporting SR authors' conclusions were of low or very low quality. Nonetheless, health system leaders seeking to improve medication adherence should prioritize interventions that have been studied and found to be effective at improving patient adherence, including dose simplification, education, reminders, and financial incentives.

Behavioral Economic Insights to Improve Medication Adherence in Adults with Chronic Conditions: A Scoping Review

BACKGROUND AND OBJECTIVE

Medication adherence is poor in patients with chronic conditions. Behavioral economic interventions may reduce biases that are associated with poor adherence. The objective of this review is to map the available evidence on behavioral economic interventions to improve medication adherence in adults with chronic conditions in high-income settings.

METHODS

We conducted a scoping review and reported the study using the Joanna Briggs Institute Reviewers' Manual and the PRISMA Extension for Scoping Review checklist. We searched PubMed, EMBASE, SCOPUS, PsycINFO, EconLit, and CINAHL from database inception to 29 August, 2018 for peer-reviewed studies and included a search of the gray literature. Data on study characteristics, study design, and study outcomes were extracted by one reviewer. Twenty-five percent of the studies were verified by a second reviewer.

RESULTS

Thirty-four studies, targeting diabetes mellitus, human immunodeficiency virus, and cardiovascular and renal diseases met our inclusion criteria. All but two studies were from the USA. The majority of interventions used financial incentives, often in conjunction with other behavioral economic concepts. Non-financial interventions included framing, social influences, reinforcement, and feedback. The effectiveness of interventions was mixed.

CONCLUSIONS

Behavioral economic informed interventions show promise in terms of improving medication adherence. However, there is no single simple intervention. This review highlighted the importance of targeting non-adherent patients, understanding their reasons for non-adherence, providing reminders and feedback to patients and physicians, and measuring clinical outcomes in addition to medication adherence. Further research in settings that differ from the US health system is needed.

MAP: A mnemonic for mapping BCTs to three routes to behaviour change

OBJECTIVE

Over 90 behaviour change techniques (BCTs) have been specified but there is limited guidance to assist non-specialist practitioners in the choice of which BCTs to select for use with clients. This paper describes the development of MAP, a theory-based mnemonic designed to aid practitioners in their use of BCTs. Each BCT is MAPed to one or more of three recognized routes to behaviour change, namely Motivation development, Action control, and Prompted or cued route.

DESIGN

A cross-sectional online discriminant content validity (DCV) questionnaire.

METHODS

Fourteen judges participated, decided whether each BCT affects behaviour via each of the three routes, and provided a confidence rating for each judgement. Wilcoxon one-sample tests classified each BCT to a route or combination of routes. Intraclass correlation coefficients (ICC) assessed agreement between judges.

RESULTS

Fifty-eight BCTs were judged to affect behaviour via a single route; 28, 21, and nine BCTs were judged to act via the Motivation, Action, or Prompted routes, respectively. Judges did not agree on a route for 35 BCTs. Overall ICC (0.89) value was high and did not differ between routes.

CONCLUSIONS

There was good agreement on candidate BCTs for interventions designed to operate through Motivation, Action, or Prompted/Cued psychological processes. MAP is a mnemonic that can be used by non-specialist practitioners who implement behaviour change with their clients. MAP is not a replacement for sophisticated theory-based organization of BCTs required for theory testing. While providing practical guidance, further work is necessary to establish effectiveness of BCTs tailored to each route.

Leveraging Mobile Sensing to Understand and Develop Intervention Strategies to Improve Medication Adherence

Interventions to improve medication adherence have had limited success and can require significant human resources to implement. Research focused on improving medication adherence has undergone a paradigm shift, of late, with a shift towards developing personalized, theory-driven interventions. The current research integrates foundational and translational science to implement a mechanisms-focused, context-aware approach. Increasing adoption of mobile and wearable sensing systems presents new opportunities for understanding how medication-taking behaviors unfold in natural settings, especially in populations who have difficulty adhering to medications. When combined with survey and ecological momentary assessment data, these mobile and wearable sensing systems can directly capture the context of medication adherence in situ, including personal, behavioral, and environmental factors. The purpose of this paper is to present a new transdisciplinary research framework in medication adherence, highlight critical advances in this rapidly-evolving research field, and outline potential future directions for both research and clinical applications.

Peers Keep It Real: Re-engaging Adults in HIV Care

Background:

After diagnosis, a substantial number of people with HIV disease fall out of care. Effective interventions are needed for this priority population.

Methods:

The “Peers Keep It Real” study aimed to help adults who were disengaged from HIV treatment. Peers, lay individuals living with HIV, facilitated intervention sessions. Participants were randomized to immediately receive the peer-facilitated intervention or were wait-listed.

Results:

Considerable attrition occurred in the control group. Pre-/postanalyses showed that among participants (n = 23) who received the intervention, 65% had viral load suppression and 100% remained in care at 12 months postintervention. Impact on viral load was significant (P = .0326), suggesting that peers are effective change agents who positively impacted outcomes for individuals struggling with adherence to HIV treatment.

Conclusion:

Future endeavors should consider providing all individuals from this priority population with an active peer intervention from the onset to enhance retention and adherence.

How far are we from a medication use process aiming at well-informed adherent patients with long-term medications in Finland? Qualitative study

OBJECTIVE

Finland is one of the few countries that has established a national Medicines Information (MI) Strategy. The ultimate goal of the strategy is a well-implemented medication use process resulting in well-informed adherent patients. This study aimed at evaluating the implementation of the strategy 3 years after its launch.

DESIGN

The evaluation applied a pragmatic approach and was conducted by interviewing stakeholders involved in the National MI Network enhancing the MI Strategy's implementation. The network comprises national key stakeholders producing and using MI. Data were deductively analysed according to the medication use process of the MI Strategy using the framework method, complemented with inductively derived categories.

SETTING

National implementation of the MI Strategy throughout the healthcare system after the first operational period (2012-2014) in 2015.

PARTICIPANTS

The members of the National MI Network (n=79/111, participation rate 71%, representing 42/53 stakeholder organisations).

OUTCOME MEASURES

A new conceptual framework was developed based on stakeholders' views on well-implemented actions and actions needing development in the medication use process at (1) infrastructure (macro), (2) healthcare professionals (meso) and (3) patient (micro) levels.

RESULTS

Medication counselling by community pharmacists was the primary implemented action, followed by physicians' actions while starting a new medication, and advice given by nurses. The major development needs concerned (1) poor access to patient information and its transfer in healthcare, particularly the lack of reconciled medication lists and electronic health records (macro); (2) poorly functioning medication use process in home care and social care units, such as nursing homes (meso); and (3) limited patient involvement in their care (micro).

CONCLUSIONS

Far more actions for development than well-established practices in the medication use process were identified. Major challenges found in this evaluation are considered in the ongoing Rational Pharmacotherapy Action Plan 2018-2022 by the Ministry of Social Affairs and Health.