A holistic conceptual framework model to describe medication adherence in and guide interventions in diabetes mellitus

Acceptability of community health worker and peer supported interventions for ethnic minorities with type 2 diabetes: a qualitative systematic review

Objective

Ethnic minority groups in high income countries in North America, Europe, and elsewhere are disproportionately affected by T2DM with a higher risk of mortality and morbidity. The use of community health workers and peer supporters offer a way of ensuring the benefits of self-management support observed in the general population are shared by those in minoritized communities.

Materials and methods

The major databases were searched for existing qualitative evidence of participants' experiences and perspectives of self-management support for type 2 diabetes delivered by community health workers and peer supporters (CHWPs) in ethnically minoritized populations. The data were analysed using Sekhon's Theoretical Framework of Acceptability.

Results

The results are described within five domains of the framework of acceptability collapsed from seven for reasons of clarity and concision: Affective attitude described participants' satisfaction with CHWPs delivering the intervention including the open, trusting relationships that developed in contrast to those with clinical providers. In considering Burden and Opportunity Costs, participants reflected on the impact of health, transport, and the responsibilities of work and childcare on their attendance, alongside a lack of resources necessary to maintain healthy diets and active lifestyles. In relation to Cultural Sensitivity participants appreciated the greater understanding of the specific cultural needs and challenges exhibited by CHWPs. The evidence related to Intervention Coherence indicated that participants responded positively to the practical and applied content, the range of teaching materials, and interactive practical sessions. Finally, in examining the impact of Effectiveness and Self-efficacy participants described how they changed a range of health-related behaviours, had more confidence in dealing with their condition and interacting with senior clinicians and benefitted from the social support of fellow participants and CHWPs.

Conclusion

Many of the same barriers around attendance and engagement with usual self-management support interventions delivered to general populations were observed, including lack of time and resource. However, the insight of CHWPs, their culturally-sensitive and specific strategies for self-management and their development of trusting relationships presented considerable advantages.

Exploring the Relationship Between Medication Adherence and Diabetes Disparities among Hispanic Patients in a Large Health System

BACKGROUND

Sub-optimal HbA1c control is a driver of disparities in diabetes outcomes among Hispanic patients. Differences in medication adherence may underlie racial/ethnic differences in HbA1c level.

OBJECTIVE

To examine the relationship between medication adherence and disparities in HbA1c level among Hispanic patients, relative to other racial/ethnic groups, obtaining care in the University of California Health System (UC Health).

DESIGN

This study used clinical, administrative, and prescription dispensing data (January-December 2021) derived from the electronic health records of 5 Academic Medical Centers in UC Health, and linear regression models (LRMs) to conduct a cross-sectional analysis of the association between medication adherence, race/ethnicity, and HbA1c level. Adjusted LRMs were run with and without the measure of medication adherence to assess this relationship.

PARTICIPANTS

Patients with a UC Health primary care physician (PCP), with ≥ 1 PCP visit within the last 3 years, ages 18-75, reporting Asian, Hispanic, or White race/ethnicity, and who had ≥ 2 encounters with an ICD diagnosis of diabetes or had a prescription for a diabetes medication within the last 2 years, as of 12/31/21 (N = 27, 542; Asian = 6253, Hispanic = 7216, White = 14,073).

MAIN MEASURES

Our measure of medication adherence was the proportion of days covered (PDC) for diabetes medications in 2021. Our outcome was the most recent HbA1c value.

KEY RESULTS

In the LRM excluding the PDC, Hispanic ethnicity was positively associated with HbA1c level (β = 0.31, p =  < 0.001). In the LRM model including PDC, PDC was negatively associated with HbA1c level (β =  - 0.18, p =  < 0.001). However, the positive relationship between Hispanic ethnicity and HbA1c level did not change (β = 0.31, p =  < 0.001).

CONCLUSIONS

The findings of this study suggest that the relationship between Hispanic ethnicity, HbA1c level, and factors outside of medication adherence should be explored among primary care patients receiving care in Academic Medical Centers.

A Qualitative Study of Barriers to Medication-Taking Among People With Type 2 Diabetes Using the Theoretical Domains Framework

Objective

We aimed to better understand the challenges related to type 2 diabetes medication-taking through Theoretical Domains Framework (TDF)-guided interviews with people with type 2 diabetes with varying degrees of medication-taking.

Methods

One-on-one qualitative interviews following a semistructured discussion guide informed by the TDF were conducted. Thirty people with type 2 diabetes in Canada were interviewed, with representation from across the country, of both sexes (47% female), of people with various diabetes durations (mean 12.9 ± 7.9 years), with different types of medication plans (n = 15 on polypharmacy), and with various medication-taking levels (n = 10 each for low-, medium-, and high-engagement groups).

Results

Themes related to medication-taking from interviews mapped to 12 of the 14 TDF theme domains, with the exclusion of the knowledge and skills domains. The most prominent domains, as determined by high-frequency themes or themes for which people with low and high medication-taking had contrasting perspectives, were 1) emotion; 2) memory, attention, and decision processes; 3) behavioral regulation; 4) beliefs about consequences; 5) goals; and 6) environmental context and resources.

Conclusion

Through our interviews, several areas of focus emerged that may help efforts to increase medication-taking. To validate these findings, future quantitative research is warranted to help support people with type 2 diabetes in overcoming psychological and behavioral barriers to medication-taking.

Association of treatment satisfaction and physician trust with glycemic control among primary care patients with type 2 diabetes in Egypt

Objectives

To evaluate the association of diabetes treatment satisfaction and trust in family physicians with glycemic control among primary care patients with type 2 diabetes mellitus.

Methods

A cross-sectional study on 319 patients with type 2 diabetes mellitus from five primary healthcare centers in Egypt. Data were collected from February to August 2021 using a structured questionnaire that contained six parts: sociodemographic data, disease profile, the Diabetes Treatment Satisfaction Questionnaire (DTSQ), 8-item Morisky Medication Adherence Scale (MMAS-8), self-reported medication knowledge questionnaire (MKQ), and revised healthcare relationship trust scale (HCR). Multiple linear regression analysis was used to assess predictors of treatment satisfaction, physician trust, and HbA1c level. P values less than 0.05 were considered significant.

Results

The mean age was 59.66 years (± 7.87 years) and 55.17% were females. Multiple linear regression analysis for predicting HbA1c showed that HbA1c level was lower in patients with higher treatment satisfaction scores (β =  - 0.289, p < 0.001) and higher medication adherence scores (β =  - 0.198, p = 0.001). Treatment satisfaction scores were positively predicted by higher physician trust scores (β = 0.301, p < 0.001), increased medication adherence scores (β = 0.160, p = 0.002), and longer duration of diabetes (β = 0.226, p < 0.001). Positive predictors for physician trust included HbA1c level (β = 0.141, p = 0.012), medication knowledge (β = 0.280, p < 0.001), diabetes treatment satisfaction (β = 0.366, p < 0.001) and medication adherence (β = 0.146, p = 0.011).

Conclusion

Optimizing diabetes treatment satisfaction and physician trust could have favorable associations with medication adherence and medication knowledge with a possible improvement in glycemic control. Family physicians should incorporate patients reported outcomes alongside traditional clinical measures in evaluating diabetes management in primary care.

Current evidence for designing self-management support for underserved populations: an integrative review using the example of diabetes

AIMS

With numerous and continuing attempts at adapting diabetes self-management support programmes to better account for underserved populations, its important that the lessons being learned are understood and shared. The work we present here reviews the latest evidence and best practice in designing and embedding culturally and socially sensitive, self-management support programmes.

METHODS

We explored the literature with regard to four key design considerations of diabetes self-management support programmes: Composition - the design and content of written materials and digital tools and interfaces; Structure - the combination of individual and group sessions, their frequency, and the overall duration of programmes; Facilitators - the combination of individuals used to deliver the programme; and Context - the influence and mitigation of a range of individual, socio-cultural, and environmental factors.

RESULTS

We found useful and recent examples of design innovation within a variety of countries and models of health care delivery including Brazil, Mexico, Netherlands, Spain, United Kingdom, and United States of America. Within Composition we confirmed the importance of retaining best practice in creating readily understood written information and intuitive digital interfaces; Structure the need to offer group, individual, and remote learning options in programmes of flexible duration and frequency; Facilitators where the benefits of using culturally concordant peers and community-based providers were described; and finally in Context the need to integrate self-management support programmes within existing health systems, and tailor their various constituent elements according to the language, resources, and beliefs of individuals and their communities.

CONCLUSIONS

A number of design principles across the four design considerations were identified that together offer a promising means of creating the next generation of self-management support programme more readily accessible for underserved communities. Ultimately, we recommend that the precise configuration should be co-produced by all relevant service and patient stakeholders and its delivery embedded in local health systems.

Perspectives of older people with uncontrolled type 2 diabetes mellitus towards medication adherence: A qualitative study

BACKGROUND

Better medication adherence among people with diabetes mellitus was found to be associated with improved glycaemic control. However, medication non-adherence is a significant concern in older people with uncontrolled type 2 diabetes mellitus.

PURPOSE

To explore the perspectives of older people with uncontrolled type 2 diabetes mellitus towards medication adherence.

DESIGN

A qualitative descriptive exploratory study.

METHODOLOGY

A purposive sample of older people with uncontrolled type 2 diabetes mellitus living in the community was recruited. Snowball sampling was applied in community recruitment. In-depth telephone interviews were conducted using a semi-structured interview guide. Interviews were transcribed verbatim. Thematic analysis was used in data analysis. The consolidated criteria for reporting qualitative research (COREQ) guidelines were followed.

RESULTS

The emerged six themes were: (a) impact of knowledge, attitudes and practices on medication adherence, (b) treatment-related barriers to medication adherence, (c) impact of age-related changes on medication adherence, (d) person-related barriers to medication adherence, (e) impact of COVID-19 on medication adherence and, (f) role of support systems in medication adherence. Knowledge of the disease process and medications, attitudes towards medication adherence, the practice of different treatment approaches, self-medication and dosing, negative experiences related to medications, polypharmacy, changes in lifestyle and roles, the influence of work-life, motivation, negligence, family support, support received from health workers, facilities available and financial capability are the main factors influence medication adherence. Age-related memory impairment, visual disturbances and physical weaknesses affect medication adherence in older people. Additionally, COVID-19-related guidelines imposed by the government and healthcare system-related issues during the COVID-19 pandemic also affected medication adherence.

CONCLUSION

Adherence to medications among older people is hampered by a variety of factors, including their knowledge, attitudes and practices, person and treatment-related factors and age-related changes. The COVID-19 pandemic has brought additional challenges. Individualised patient care for older people with uncontrolled type 2 diabetes mellitus to improve medication adherence is timely. Strengthening support mechanisms for the above population is essential.

A Qualitative Study on the Perception of Medication Adherence by the Social Circles of Patients with Type 2 Diabetes

Introduction

Studies have indicated that half of all patients with diabetes do not take their medication as prescribed. Patient social circles, including professionals (health care providers) and nonprofessionals (family and friends) might contribute to low medication adherence. Therefore, this study explored the point of view of healthcare providers and family members of patients with diabetes on patient medication adherence.

Methods

Our study included health care providers and family members using in-depth, semi structured interviews. The theoretical domain framework (TDF) was used to explore their perspectives. TDF was used to build a topic guide and to frame the data analysis. The interviews were transcribed verbatim and thematically analyzed using the MAXQDA 2022 program.

Results

The participants identified a variety of factors potentially associated with diabetes medication adherence. Most factors were related to the environmental context and resources such as the burden of polypharmacy, medication shortages, and long wait times for care. In addition, factors related to patient beliefs concerning diabetes complications and insulin injections were reported. Several factors were identified that related to knowledge and social influences.

Discussion

Interventions that target the factors identified by the social circle of patients with diabetes might improve medication adherence and promote better disease management outcomes.

Socio-cognitive determinants affecting insulin adherence/non-adherence in late adolescents and young adults with type 1 diabetes: a systematic review protocol

Objective

This systematic review aims to investigate the key socio-cognitive determinants associated with adherence/non-adherence to insulin treatment in late adolescents and young adults in the age range of 17–24 years with T1D.

Methods

A pre-specified search strategy will be used to search for studies in the electronic databases and citation indexes: PubMed, EMBASE, Web of Science, and PsycINFO. Two researchers will screen the title and the abstract independently, then will read and critically appraise the full text of each included study. A third independent reviewer will resolve disagreements in data extraction until consensus. Data will be extracted using the Population, Exposure, Outcomes, Study characteristics framework. Study selection will follow the updated guideline for reporting systematic reviews (PRISMA 2020) and will take place from 15 October 2021 to 1 January 2022. The methodological quality and risk of bias of the observational studies will be assessed by the JBI Critical Appraisal Checklist for Cohort and JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies.

Results

A qualitative narrative synthesis will present the characteristics and the quality of studies and the outcomes of concern.

Conclusion

Based on the contemporary literature, this review will synthesize the evidence on the socio-cognitive determinants associated with adherence/non-adherence to insulin treatment in late adolescents and young adults in the age range of 17–24 years with T1D. The findings will help design patient-centered interventions to promote adherence to insulin in this age group, guide patients’ consultations and diabetes self-management education (DSME) programs.

Protocol registration: PROSPERO ID: CRD42021233074.

Exploring of Determinants Factors of Anti-Diabetic Medication Adherence in Several Regions of Asia - A Systematic Review

BACKGROUND

The determinants of medication adherence in people with diabetes may differ between populations of an area due to social environment, cultural beliefs, socioeconomic conditions, education, and many other factors differences.

OBJECTIVE

Therefore, this study aims to explore, identify and classify the determinants of medication adherence in several Asian regions.

METHODS

A systematic literature review was conducted to gain insight into the determinants of medication adherence. Seven relevant databases (EBSCO, ProQuest, PubMed, ScienceDirect, Scopus, Wiley, dan Taylor and Francis) and hand searching methods were conducted from January 2011 to December 2020. Keywords were compiled based on the PICO method. The selection process used the PRISMA guidelines based on inclusion, and the quality was assessed using Crowe's critical assessment tool. Textual summaries and a conceptual framework model of medication adherence were proposed to aid in the understanding of the factors influencing medication adherence.

RESULTS

Twenty-six articles from countries in several Asian regions were further analyzed. Most studies on type 2 diabetes patients in India used the MMAS-8 scale, and cross-sectional study is the most frequently used research design. The medication adherence rate among diabetic patients was low to moderate. Fifty-one specific factors identified were further categorized into twenty-three subdomains and six domains. Furthermore, the determinants were classified into four categories: inconsistent factors, positively related factors, negatively related factors, and non-associated factors. In most studies, patient-related factors dominate the association with medication adherence. This domain relates to patient-specific demographics, physiological feelings, knowledge, perceptions and beliefs, comorbidities, and other factors related to the patient. Several limitations in this review need to be considered for further research.

CONCLUSION

Medication adherence to diabetic therapy is a complex phenomenon. Most determinants produced disparate findings in terms of statistical significance. The identified factors can serve various goals related to medication adherence. Policymakers and health care providers should consider patient-related factors.

An Adaptable Framework for Factors Contributing to Medication Adherence: Results from a Systematic Review of 102 Conceptual Frameworks

OBJECTIVE

To summarize the available conceptual models for factors contributing to medication adherence based on the World Health Organization (WHO)'s five dimensions of medication adherence via a systematic review, identify the patient groups described in available conceptual models, and present an adaptable conceptual model that describes the factors contributing to medication adherence in the identified patient groups.

METHODS

We searched PubMed®, Embase®, CINAHL®, and PsycINFO® for English language articles published from inception until 31 March 2020. Full-text original publications in English that presented theoretical or conceptual models for factors contributing to medication adherence were included. Studies that presented statistical models were excluded. Two authors independently extracted the data.

RESULTS

We identified 102 conceptual models, and classified the factors contributing to medication adherence using the WHO's five dimensions of medication adherence, namely patient-related, medication-related, condition-related, healthcare system/healthcare provider-related, and socioeconomic factors. Eight patient groups were identified based on age and disease condition. The most universally addressed factors were patient-related factors. Medication-related, condition-related, healthcare system-related, and socioeconomic factors were represented to various extents depending on the patient group. By systematically examining how the WHO's five dimensions of medication adherence were applied differently across the eight different patient groups, we present a conceptual model that can be adapted to summarize the common factors contributing to medication adherence in different patient groups.

CONCLUSION

Our conceptual models can be utilized as a guide for clinicians and researchers in identifying the facilitators and barriers to medication adherence and developing future interventions to improve medication adherence.

PROTOCOL REGISTRATION

PROSPERO Identifier: CRD42020181316.

Analysis of the Impact of Disease Acceptance, Demographic, and Clinical Variables on Adherence to Treatment Recommendations in Elderly Type 2 Diabetes Mellitus Patients

This project aimed to analyze the impact of disease acceptance and selected demographic and clinical factors on the adherence to treatment recommendations in elderly type 2 diabetes mellitus patients. The observational study was performed using standardized research questionnaires: the Acceptance of Illness Scale (AIS), the Self-Care of Diabetes Inventory (SCODI), and the Adherence in Chronic Diseases Scale (ACDS). Two hundred patients with T2DM were studied (age M = 70.21 years, SD = 6.63 years). The median degree of disease acceptance was 29 (min-max = 8-40) and the median level of adherence was 24 (min-max = 13-28). Disease acceptance was a significant (p = 0.002) independent predictor of the odds of qualifying for non-adherence OR = 0.903, 95% CI = 0.846-0.963. The respondents gave the lowest scores for glycemic control (Mdn = 38.99, min-max = 8.33-150), and health control (Mdn = 55.88, min-max = 11.76-100). A one-way ANOVA showed that the non-adhering patients were significantly older compared to the adherence group and were taking significantly more diabetes pills per day. The level of disease acceptance was average, but it turned out to be an independent predictor of adherence. Therefore, it is justified to use psychological and behavioral interventions that are aimed at increasing the level of diabetes acceptance in elderly people with T2DM. It is important to have a holistic approach to the patient and to take actions that consider the patient's deficits in the entire biopsychosocial sphere. The obtained result confirmed the legitimacy of interventions aimed at increasing the level of disease acceptance in this group of patients.

Exploring medication self-management in community-dwelling adults with chronic medication experience: A concept mapping study

BACKGROUND

People who take medications often experience challenges including making decisions about risks versus benefits and integrating medication management with all aspects of life (e.g., social and work responsibilities). Existing medication self-management frameworks are primarily adherence-focused and lack integrating holistic perspectives.

OBJECTIVE

To explore the priorities of people with chronic medication experience (i.e., take at least 1 medication daily for at least 3 months) and what they can contribute to the understanding of medication self-management.

METHODS

Concept mapping is a participatory, mixed-methods approach with 3 stages: brainstorming, sorting/rating, and mapping. Group brainstorming discussions were held with participants who generated statements about what mattered to them regarding medications in their everyday lives. In sorting/rating, individual participants grouped statements into thematic piles and rated their importance and feasibility. During mapping, a subset of participants discussed and agreed on a visual map and named the statement clusters. Following mapping, the researchers analyzed rating results, stratified by participant characteristics (gender, age, duration of medication use, number of medications, and chronic conditions).

RESULTS

Sixty-three participants generated 1044 statements during 8 brainstorming sessions, which the researchers synthesized into 94 statements. Fifty-four participants individually sorted and rated the statements. Most statements were rated highly on both importance and feasibility, regardless of participant characteristics. Eight participants attended the mapping session. The final map had 9 thematic clusters, which were named by participants as: 1) researching and becoming educated about medications; 2) social support; 3) effectiveness of medication; 4) self-ownership of medication; 5) ease of use; 6) convenience and accessibility; 7) information provided by healthcare provider; 8) personal interactions with healthcare provider; and 9) patient involvement and trust.

CONCLUSIONS

Results enhance existing medication management frameworks by providing a more comprehensive perspective. Understanding medication self-management requires more research that incorporates and prioritizes the perspectives of individuals who manage their medications.

Adherence to oral appliance treatment and its determinants in obstructive sleep apnoea patients

BACKGROUND AND OBJECTIVES

Treatment effectiveness, in terms of health benefits, is a composite of efficacy and adherence. Oral appliance (OA) usage is mainly based on self-reports, but nowadays, objective adherence monitoring for OAs is available. This study investigated the objective OA adherence and its determinants in obstructive sleep apnoea (OSA) patients.

MATERIALS AND METHODS

There were 29 subjects who were treated with OA; mean [SD] age 51.4 [11.1]; mean apnoea-hypopnoea index (AHI) [SD] 19.5 [10.0]. Anthropometric and sociodemographic parameters, AHI, daytime sleepiness, snoring, and adverse effects of OA as potential determinants were evaluated. Patients were classified as regular users if they wore OA at least 4 hours nightly 5-7 nights a week. Statistical analyses included the chi-square test, t-test, Mann-Whitney U-test, and linear regression analyses.

RESULTS

At the 3-month follow-up, 68% of subjects were regular users and at 12-month follow-up, 64%. AHI, sociodemographic parameters, or adverse effects were not associated with OA adherence. Snoring seemed to improve weakly adherence, whereas mandibular retrusion reduced the weekly use, and smoking the nightly use of OAs.

LIMITATIONS

The follow-up time was short, and there were a relatively small number of patients with obtainable adherence data, therefore it is difficult to establish if OA therapy alone is a successful long-term treatment option for OSA patients.

CONCLUSIONS/IMPLICATIONS

Adherence to OA therapy is mainly the outcome of patients' subjective comfort in everyday life through eliminating social disturbance of snoring. To best meet a subject's individual treatment need and to prevent suboptimal use of OA, a patient-tailored therapy including digital wear-time documentation is recommended.

Relational Dynamics of Treatment Behavior Among Individuals with Tuberculosis in High-Income Countries: A Scoping Review

Although tuberculosis (TB) incidence has significantly declined in high-income, low-incidence (HILI) countries, challenges remain in managing TB in vulnerable populations who may struggle to stay on anti-TB treatment (ATT). Factors associated with non-adherence to ATT are well documented; however, adherence is often narrowly conceived as a fixed binary variable that places emphasis on individual agency and the act of taking medicines, rather than on the demands of being on treatment more broadly. Further, the mechanisms through which documented factors act upon the experience of being on treatment are poorly understood. Adopting a relational approach that emphasizes the embeddedness of individuals within dynamic social, structural, and health systems contexts, this scoping review aims to synthesize qualitative evidence on experiences of being on ATT and mechanisms through which socio-ecological factors influence adherence in HILI countries. Six electronic databases were searched for peer-reviewed literature published in English between January 1990 and May 2020. Additional studies were obtained by searching references of included studies. Narrative synthesis was used to analyze qualitative data extracted from included studies. Of 28 included studies, the majority (86%) reported on health systems factors, followed by personal characteristics (82%), structural influences (61%), social factors (57%), and treatment-related factors (50%). Included studies highlighted three points that underpin a relational approach to ATT behavior: 1) individual motivation and capacity to take ATT is dynamic and intertwined with, rather than separate from, social, health systems, and structural factors; 2) individuals' pre-existing experiences of health-seeking influence their views on treatment and their ability to commit to long-term regular medicine-taking; and 3) social, cultural, and political contexts play an important role in mediating how specific factors work to support or hinder ATT adherence behavior in different settings. Based on our analysis, we suggest that person-centered clinical management of tuberculosis should 1) acknowledge the ways in which ATT both disrupts and is managed within the everyday lives of individuals with TB; 2) appreciate that individuals' circumstances and the support and resources they can access may change over the course of treatment; and 3) display sensitivity towards context-specific social and cultural norms affecting individual and collective experiences of being on ATT.

The development of an integrated behavioural model of patient compliance with diabetes medication: a mixed-method study protocol

BACKGROUND

There has been a shift in worldwide disease burden from infections to non-communicable diseases, especially type 2 diabetes (T2D). Behavioural change and self-management are key to optimal T2D control. Several universal models of diabetic care have been proposed to help explain the dimensions of T2D self-care such as medication adherence, physical activity, diet and patient-doctor interaction. These models do not allow an objective and quantifiable measurement of the problems faced by patients in terms of medication compliance.

OBJECTIVE

To create a comprehensive conceptual model of behavioural change related to T2D medication compliance.

METHODS

A cross-sectional study will be conducted at a regional primary care clinic using a mixed-method technique. First, a Grounded Theory qualitative inquiry will be used to investigate predictors of medication adherence in T2D patients. Consequently, the elements derived from the interview will be incorporated into the Theory of Planned Behaviour framework to generate an integrated behavioural model. This model will then be used to quantify the factors related to compliance with medication amongst T2D patients.

DISCUSSION

The framework developed here could help in the design of policies to optimize T2D control by identifying lapses in patients' intake of diabetic medications. This can be done by exploring the patients' fundamental and unarticulated belief system via a naturalistic approach adopted in this study. The properties of the framework can be replicated in other settings to serve as a benchmark for quality improvement in T2D patient care.

Triple strength utility of the Modified Drug Adherence Work-Up (M-DRAW) tool in a veterans affairs outpatient diabetes clinic

OBJECTIVE

The purpose of this study was to test the psychometric properties of the M-DRAW tool and to examine its applicability and utility at a primary clinic setting in patients with diabetes.

METHODS

A prospective, pre-post interview design study was conducted at the VA Loma Linda Health System (VALLHS) from 03/2017-03/2018. Eligibility criteria consisted of English-speaking patrons who were 18 years and older, diagnosed with Type 2 diabetes mellitus, residing in non-institutional setting, and having 1 + prescriptions for diabetes. A priming question about self-reported adherence was used to assign participants to control (Group A) or intervention (Group N). Pharmacist-led interventions were thus directed to those who recognized their medication nonadherence issue. The M-DRAW tool consisted of 13 statements about barriers to adherence on a 4-point frequency scale. A "3 = sometimes" or "4 = often" on each item indicated a barrier to adherence that was then addressed using the GUIDE strategy using motivational interviewing with the participant.

RESULTS

Of the 200 eligible individuals, 88 participants completed both baseline and follow-up assessments (Group A, n = 63; Group N, n = 25). Participants were male (98.8%), taking 7-8 medications on average, and using insulin (79.5%). The tool yielded good internal consistency (Cronbach's alpha = 0.873). Using confirmatory factor analysis, four factors were extracted with items loading as hypothesized. At baseline, group N identified three times greater number of barriers from the M-DRAW tool compared to Group A (5.1 items vs. 1.7, p < 0.05). At 3-month follow-up, a decrease in the number of barriers was observed among Group N. Both PDC and HbA1c did not result in statistically significant reduction in pre-post change.

CONCLUSIONS

The M-DRAW tool is shown to be reliable and valid. A tailored intervention reduced the number of barriers contributing to medication nonadherence and resulted in a trend of improved clinical outcomes.

Pilot and Feasibility of Combining a Medication Adherence Intervention and Group Diabetes Education for Patients with Type-2 Diabetes

Introduction: Controlling diabetes typically requires self-management and medications. Community pharmacists are positioned to support patients with both. Methods: This study assessed the feasibility and potential benefit of combining pharmacist-provided group diabetes education (up to eight sessions) and medication synchronization using a three-group design. Data were collected using pre-post paper surveys and electronic health record data. One group received both education and synchronization services, another group received medication synchronization only, and a third served as control. Results: Of 300 contacted patients, eighteen patients participated in group diabetes education, 14 had medication synchronization only, and 12 comprised a control group. There was little change in HbA1c over the study period. Medication adherence appeared to be positively aided by medication synchronization, although all groups started with high adherence. Some medication beliefs and self-care activities may have been positively impacted by group diabetes education. Both groups receiving medication synchronization were satisfied. Conclusions: Participants strongly agreed they would recommend group diabetes education from the study pharmacy to a friend and were satisfied with medication synchronization; however, it was difficult to tell if there was a synergistic effect by combining the two services. Reimbursement for diabetes education was not obtained despite multiple attempts, hindering sustainability.

A qualitative exploration of barriers to medication adherence among patients with uncontrolled diabetes in Qatar: integrating perspectives of patients and health care providers

PURPOSE

To develop an in-depth understanding of the barriers to medication adherence among patients with uncontrolled diabetes attending primary health care (PHC) centers in Qatar by exploring and integrating patients' and health care providers' perspectives.

PARTICIPANTS AND METHODS

A descriptive qualitative methodology was used in this study. A trained researcher conducted semi-structured face-to-face interviews at two PHC centers. Patients with uncontrolled diabetes (with varied sociodemographic characteristics) and their respective health care providers (physicians, pharmacists, nurses, dieticians, and others) were purposively selected from the two PHC centers. All interviews were audio recorded, transcribed verbatim, and analyzed using thematic content analysis.

RESULTS

Thirty interviews (14 patients and 16 health care providers) were conducted. A number of barriers to medication adherence were identified and classified broadly under three main themes: 1) patient-related factors, which included patients' individual characteristics and patients' perception, attitude, and behavior; 2) patient-provider factors, which included communication and having multiple health care providers caring for the patient; and 3) societal and environmental factors, which included social pressure and traveling to visit friends and relatives.

CONCLUSION

Patients with uncontrolled diabetes face multiple barriers to medication adherence. Similar themes emerged from both patients and their care providers. This research highlights the need for concerted multidimensional efforts and series of interventions to overcome these barriers. One vital intervention is expanding the scope of pharmacists' role within the PHC centers through providing medication reconciliation, patient-tailored medication counseling, and medicines use review, which may improve treatment outcomes among patients with diabetes.