A person-centred primary care pharmacist-led osteoporosis review for optimising medicines (PHORM): a protocol for the development and co-design of a model consultation intervention

INTRODUCTION

Adherence to medicines in osteoporosis is poor, with estimated 1 year persistence rates between 16% and 60%. Poor adherence is complex, relating to combinations of fear of side effects, beliefs about medication being unnecessary, doubts about effectiveness and the burden of medication management. This is compounded by an absence of monitoring, as many patients are effectively discharged from ongoing care following the initial prescription. Clinical pharmacists in general practice are a relatively new workforce in the UK NHS; this is an unexplored professional group that could provide person-centred, adherence-focused interventions in an osteoporosis context.A model consultation intervention to be delivered by clinical pharmacists in general practice for patients already prescribed fracture prevention medications will be developed using existing evidence and theory and empirical qualitative work outlined in this protocol.

METHODS AND ANALYSIS

We will investigate the current practice and barriers and facilitators to a clinical pharmacist-led osteoporosis intervention, including exploring training needs, through focus groups with people living with osteoporosis, pharmacists, general practitioners, osteoporosis specialists and service designers/commissioners. Framework analysis will identify and prioritise salient themes, followed by mapping codes to the theoretical domains framework and normalisation process theory to understand integration and implementation issues.We will further develop the content and model of care for the new consultation intervention through co-design workshops with stakeholder and patient and public involvement and engagement group members. The intervention in practice will be refined in a sequential process with workshops and in-practice testing with people prescribed fracture prevention medication, pharmacists and the multidisciplinary team.

ETHICS AND DISSEMINATION

Ethical approval was obtained from NHS North West-Greater Manchester South Research Ethics Committee (Ref 23/NW/0199). Dissemination and knowledge mobilisation will be facilitated through a range of national bodies/stakeholders. Impact and implementation plans will accelerate this research towards a future clinical trial to determine cost and clinical effectiveness.

Reliability and validity of the Turkish version of the medication practical barriers to adherence questionnaire in patients with chronic diseases

PURPOSE

The aim of this study was to evaluate the validity and reliability of the Turkish version of the Medication Practical Barriers to Adherence Questionnaire (MPRAQ-TR).

METHODS

This is a validation study conducted between August 2022 and March 2023 in the ambulatory services of a secondary care private hospital located in Istanbul, Türkiye, among patients (18 years of age and older) with chronic diseases. After the Turkish translation and cultural adaptation of the MPRAQ, and a pilot think-aloud study, the following psychometric properties were assessed: internal consistency by calculating the Cronbach's alpha coefficient, 2-week test-retest reliability, convergent validity by calculating Spearman's rank correlation between the MPRAQ-TR and the Turkish version of Medication Adherence Report Scale (MARS), and predictive validity by evaluating the association between the MPRAQ-TR score and nonadherence to medications.

RESULTS

Among the 380 patients (response rate = 89.6%), 72.1% were nonadherent to their medications. The intraclass correlation coefficient was 0.99 for MPRAQ-TR scores (95% CI, 0.98-0.99; p < 0.001). The Cronbach's alpha of the MPRAQ-TR was 0.853. There was a moderate negative correlation between the scores on the MARS and the MPRAQ-TR (Spearman's rho = - 0.525; p < 0.01), supporting the convergent validity of the MPRAQ-TR. In the univariate analysis, the total score of MPRAQ-TR was associated with increased odds of nonadherence to medications (p < 0.01).

CONCLUSION

MPRAQ-TR shows good psychometric properties and can be used to evaluate the practical adherence barriers of patients with chronic diseases.

Racial disparities in prostate cancer in the UK and the USA: similarities, differences and steps forwards

In the USA, Black men are approximately twice as likely to be diagnosed with and to die of prostate cancer than white men. In the UK, despite Black men having vastly different ancestral contexts and health-care systems from Black men in the USA, the lifetime risk of being diagnosed with prostate cancer is two-to-three times higher among Black British men than among white British men and Black British men are twice as likely to die of prostate cancer as white British men. Examination of racial disparities in prostate cancer in the USA and UK highlights systemic, socio-economic and sociocultural factors that might contribute to these differences. Variation by ancestry could affect incidence and tumour genomics. Disparities in incidence might also be affected by screening guidelines and access to and uptake of screening. Disparities in treatment access, continuity of care and outcomes could contribute to survival differences. In both localized and metastatic settings, equal access could diminish the observed disparities in both the USA and the UK. An understanding of behavioural medicine, especially an appreciation of cultural beliefs about illness and treatment, could inform and improve the ways in which health systems can engage with and deliver care to patients in minoritized groups affected by prostate cancer. Methods of promoting equity include targeting systemic barriers including systemic racism, proportional recruitment of patients into clinical trials, diversifying the health-care workforce and facilitating care informed by cultural humility. Actively engaging patients and communities in research and intervention might enable the translation of research into increasingly equitable care for patients with prostate cancer in the UK, the USA and globally.

What do patients with heart failure disclose about medication adherence at home to their hospital and primary care doctors? Exploratory interaction-based observational cohort study

OBJECTIVES

The main objective of this study was twofold: to investigate what kind of information patients with heart failure (HF) tell their doctors about their medication adherence at home, and how often such information is provided in consultations where medication reconciliation is recommended. To meet these objectives, we developed an analysis to recognise, define, and count (1) patient utterances including medication adherence disclosures in clinical interactions (MADICI), (2) MADICI including red-flags for non-adherence, and (3) MADICI initiated by patients without prompts from their doctor.

DESIGN

Exploratory interaction-based observational cohort study. Inductive microanalysis of authentic patient-doctor consultations, audio-recorded at three time-points for each patient: (1) first ward visit in hospital, (2) discharge visit from hospital, and (3) follow-up visit with general practitioner (GP).

SETTING

Norway (2022-2023).

PARTICIPANTS

25 patients with HF (+65 years) and their attending doctors (23 hospital doctors, 25 GPs).

RESULTS

We recognised MADICI by two criteria: (1) they are about medication prescribed for use at home, AND (2) they involve patients' action, experience, or stance regarding medications. Using these criteria, we identified 427 MADICIs in 25 patient trajectories: 143 (34%) at first ward visit (min-max=0-35, median=3), 57 (13%) at discharge visit (min-max=0-8, median=2), 227 (53%) at GP-visit (min-max=2-24, median=7). Of 427 MADICIs, 235 (55%) included red-flags for non-adherence. Bumetanide and atorvastatin were most frequently mentioned as problematic. Patients initiated 146 (34%) of 427 MADICIs. Of 235 'red-flag MADICIs', 101 (43%) were initiated by patients.

CONCLUSIONS

Self-managing older patients with HF disclosed information about their use of medications at home, often including red-flags for non-adherence. Patients who disclosed information that signals adherence problems tended to do so unprompted. Such disclosures generate opportunities for doctors to assess and support patients' medication adherence at home.

Behavioral Science: Enhancing Our Approach to the Development of Effective Additional Risk Minimization Strategies

Additional risk minimization strategies may be required to assure a positive benefit-risk balance for some therapeutic products associated with serious adverse drug reactions/risks of use, without which these products may be otherwise unavailable to patients. The goals of risk minimization strategies are often fundamentally to influence the behavior of healthcare professionals (HCPs) and/or patients and can include appropriate patient selection, provision of education and counselling, appropriate medication use, adverse drug reaction monitoring, and adoption of other elements to assure safe use, such as pregnancy prevention. Current approaches to additional risk minimization strategy development rely heavily on information provision, without full consideration of the contextual factors and multi-level influences on patient and HCP behaviors that impact adoption and long-term adherence to these interventions. Application of evidence-based behavioral science methods are urgently needed to improve the quality and effectiveness of these strategies. Evidence from the fields of adherence, health promotion, and drug utilization research underscores the value and necessity for using established behavioral science frameworks and methods if we are to achieve clinical safety goals for patients. The current paper aims to enhance additional risk minimization strategy development and effectiveness by considering how a behavioral science approach can be applied, drawing from evidence in understanding of engagement with pharmaceutical medicines as well as wider public health interventions for patients and HCPs.

Development and Validation of a Tool to Explore Attitudes Towards meDication adHErence Using a Novel Self-Reported QuestionnairE (ADHERE-7)

Despite the availability of various tools for measuring medication adherence, efficiently identifying non-adherence levels and reasons at the point of care remains challenging. Existing tools often lack the ease of use needed for practical clinical application. This study aimed to develop and validate a user-friendly tool to provide healthcare professionals with a concise yet comprehensive means of identifying adherence behaviors. The methodology consisted of two phases: tool items were first developed using the nominal group technique with healthcare professionals, followed by a cross-sectional pilot study involving community-dwelling adults in Croatia. Validation analysis indicated acceptable face and content validity and satisfactory criterion validity, with Attitudes towards meDication adHErence self-Reported questionnairE (ADHERE-7) scores correlating with both the self-reported five-item Medication Adherence Report Scale (MARS-5 tool) (ρ = 0.765; p < 0.001) and an objective measure of the proportion of days covered (PDC) from pharmacy prescription claims data (G = 0.586; p = 0.015). Construct validity revealed three factors: Aversion, Comfort, and Practical Non-Adherence, with Cronbach's alpha values of 0.617 for Aversion and 0.714 for Comfort Non-Adherence. The mean total score for ADHERE-7 was 26.27 ± 2.41 (range 17 to 28). This robust validation process confirms the ADHERE-7 tool as a reliable instrument for assessing medication adherence, addressing aversion, comfort, practical issues, and both intentional and unintentional nonadherence.

Understanding patient demand for and use of antibiotics for upper respiratory tract infection: A qualitative application of the Necessity-Concerns Framework in Saudi Arabia

Background

Reducing antimicrobial resistance (AMR) is a priority for public health. Inappropriate patient demand is an important driver of unnecessary antibiotic use. To develop an effective intervention to reduce inappropriate demand for antibiotics in upper respiratory tract infections (URTIs), it is important to identify patient perceptions that influence demand for, and appropriate use of antibiotics.

Aim

To identify and describe the beliefs about antibiotics necessity and concerns that patients with URTIs have, in Riyadh, Saudi Arabia.

Method

An exploratory qualitative approach was used. One-to-one, face-to-face or telephone semi-structured interviews were conducted with participants recruited using purposive sampling (based on age and gender) from primary healthcare centre in Riyadh, Saudi Arabia were conducted. Only adult patients who currently experience URTIs symptoms and agreed to participate were recruited. Recruitment for interviews continued until data saturation point was reached. The interview guide explored patients' necessity beliefs and concerns about antibiotics, AMR perceptions, and expectations from URTIs consultation. Interview transcripts were coded using QSR NVivo 12 using framework analysis informed by the Necessity-Concerns Framework to identify key motivations driving antibiotic requests and consultations.

Results

the study interviewed 32 participants (44% were male, average age was 36.84). Results identified that the patients often relate their personal need for antibiotics when encountering an URTIs symptoms to the type, severity and duration of symptoms. Patients also linked antibiotics with quicker recovery, generally expressing few concerns about antibiotics mainly because of its short duration of use. However, some conveyed their concern about frequent administration of antibiotics and effect on the body's immune system function, which may make them more prone to infections in the future. Participants varied widely in their awareness of AMR; this was associated with many misconceptions, such as confusing AMR with antibiotics efficacy and tolerance. Interestingly, the interplay between necessity beliefs and concerns was observed to influence the decision to start and stop antibiotic, potentially impacting inappropriate antibiotic demand and unnecessary use.

Conclusion

This study highlighted important beliefs and misconceptions about antibiotics and AMR in Saudi population which can be targeted in future interventions to reduce inappropriate demand for antibiotics and optimise appropriate usage.

Health and illness beliefs in adults with tuberculosis infection during the COVID-19 pandemic in the UK

Background

COVID-19 disrupted the TB prevention programme in the UK, especially for TB infection (TBI) care. We explore whether experience of the COVID-19 pandemic impacted on patients' perceptions of TBI and its treatment.

Methods

Semi-structured interviews were conducted as part of the Research to Improve Detection and Treatment of TBI (RID-TB) programme, exploring perceptual and practical barriers to TBI treatment. Nineteen people diagnosed with TBI were interviewed between August 2020 and April 2021. Recordings were transcribed and analysed using a constant comparative approach, allowing for a dynamic and iterative exploration of themes. Themes are organised using the Perceptions and Practicalities Approach.

Findings

Some participants perceived TBI as a risk factor for increased susceptibility to COVID-19, while some thought that treatment for TBI might protect against COVID-19 or mitigate its effects. Adaptations to TB services (e.g., remote follow-up) and integrated practices during the COVID-19 restrictions (e.g., medication being posted) addressed some practical barriers to TBI treatment. However, we identified beliefs about TBI and COVID-19 that are likely to act as barriers to engagement with TBI treatment, including: interpreting service delays as an indication of TBI not being serious enough for treatment and concerns about contracting COVID-19 in TB clinics.

Interpretation

COVID-19 and TBI service delays influence people's perceptions and practical barriers to TBI treatment adherence. Failure to address these beliefs may lead to people's concerns about their treatment not being fully addressed. Utilised service adaptations like remote consultations to address practical barriers may be relevant beyond COVID-19.

Funding

NIHR RID-TB Program (RP-PG-0217-20009).

Access to a tailored mobile application enhances medication adherence among young users of antidepressants

Introduction

Patients' adherence to antidepressants is generally reported to be poor. This study examined whether users of selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) enhance medication adherence following access to a mobile application (app) tailored for this patient group. The study addresses the implementation phase of medication adherence.

Methods

The study was a single group pre-post intervention design. Data were collected using the validated OsloMet Adherence-to-medication Survey tool (OMAS-37) before and after app access. Pre-app access survey (Survey 1) was conducted via social media and online newspapers, encompassing 445 SSRI/SNRI users aged 18 years and above. Post-app access survey (Survey 2) was sent to 103 SSRI/SNRI users from Survey 1. Wilcoxon Signed Rank Test compared pre- and post-intervention adherence measurements. Pearson's chi-square tests and Fisher's exact tests compared study population categories.

Results

Forty-two SSRI/SNRI users, median age 26 (IQR 17), 93% identifying as female, used the app while using the same antidepressant during the 2-month period between gaining access to the app and Survey 2. There was a statistically significant reduction in non-adherence score post-app access (z = 3.57, n = 42, p < 0.001) with medium effect size (r = 0.39), indicating enhanced adherence. Total non-adherence score decreased by 39% from pre-to post-access, and there was a 12% decrease in users scoring equivalent with poor adherence (score <2) post-access. Twenty-nine of 37 non-adherence causes improved, with three showing statistical significance. Of 42 responders, 50% (n = 21) indicated using the app one to two times, while 50% (n = 21) more than three times. Approximately 69% (n = 28) found it useful, and 43% (n = 18) felt safer in their use of antidepressants after access to the app. No significant preference was observed for the app over alternative sources of information.

Discussion

Enhanced medication adherence was observed among antidepressant users following access to the tailored app. Further studies are warranted to evaluate the app applicability to a broader range of antidepressants users or other patient groups, encompassing those in the initiation phase of medication adherence. The app is intended as an easily accessible supplement to the information and advice provided by prescribing physicians and dispensing pharmacists.

Bisphosphonate alternative regimens for the prevention of osteoporotic fragility fractures: BLAST-OFF, a mixed-methods study

Background

Bisphosphonates are a class of medication commonly used to treat osteoporosis. Alendronate is recommended as the first-line treatment; however, long-term adherence (both treatment compliance and persistence) is poor. Alternative bisphosphonates are available, which can be given intravenously and have been shown to improve long-term adherence. However, the most clinically effective and cost-effective alternative bisphosphonate regimen remains unclear. What is the most cost-effective bisphosphonate in clinical trials may not be the most cost-effective or acceptable to patients in everyday clinical practice.

Objectives

1. Explore patient, clinician and stakeholder views, experiences and preferences of alendronate compared to alternative bisphosphonates. 2. Update and refine the 2016 systematic review and cost-effectiveness analysis of bisphosphonates, and estimate the value of further research into their benefits. 3. Undertake stakeholder/consensus engagement to identify important research questions and further rank research priorities.

Methods

The study was conducted in two stages, stages 1A and 1B in parallel, followed by stage 2: • Stage 1A - we elicited patient and healthcare experiences to understand their preferences of bisphosphonates for the treatment of osteoporosis. This was undertaken by performing a systematic review and framework synthesis of qualitative studies, followed by semistructured qualitative interviews with participants. • Stage 1B - we updated and expanded the existing Health Technology Assessment systematic review and clinical and cost-effectiveness model, incorporating a more comprehensive review of treatment efficacy, safety, side effects, compliance and long-term persistence. • Stage 2 - we identified and ranked further research questions that need to be answered about the effectiveness and acceptability of bisphosphonates.

Results

Patients and healthcare professionals identified a number of challenges in adhering to bisphosphonate medication, balancing the potential for long-term risk reduction against the work involved in adhering to oral alendronate. Intravenous zoledronate treatment was generally more acceptable, with such regimens perceived to be more straightforward to engage in, although a portion of patients taking alendronate were satisfied with their current treatment. Intravenous zoledronate was found to be the most effective, with higher adherence rates compared to the other bisphosphonates, for reducing the risk of fragility fracture. However, oral bisphosphonates are more cost-effective than intravenous zoledronate due to the high cost of zoledronate administration in hospital. The importance of including patients and healthcare professionals when setting research priorities is recognised. Important areas for research were related to patient factors influencing treatment selection and effectiveness, how to optimise long-term care and the cost-effectiveness of delivering zoledronate in an alternative, non-hospital setting.

Conclusions

Intravenous zoledronate treatment was generally more acceptable to patients and found to be the most effective bisphosphonate and with greater adherence; however, the cost-effectiveness relative to oral alendronate is limited by its higher zoledronate hospital administration costs.

Future work

Further research is needed to support people to make decisions influencing treatment selection, effectiveness and optimal long-term care, together with the clinical and cost-effectiveness of intravenous zoledronate administered in a non-hospital (community) setting.

Limitations

Lack of clarity and limitations in the many studies included in the systematic review may have under-interpreted some of the findings relating to effects of bisphosphonates.

Trial registration

This trial is registered as ISRCTN10491361.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127550) and is published in full in Health Technology Assessment; Vol. 28, No. 21. See the NIHR Funding and Awards website for further award information.

Social relationships, stress, and treatment adherence perceptions in type 2 diabetes and hypertension: between-person, within-person, and compositional associations

OBJECTIVE

Type 2 diabetes and hypertension are "intertwined" conditions with lifestyle treatment plans, but patients often struggle to consistently engage in and follow treatment plans. To identify potential mechanisms for improving patient adherence to lifestyle treatment plans for type 2 diabetes and hypertension, this longitudinal study investigated the extent to which situational changes in patient-practitioner relationships, close relationships, and stress, explain between-person, immediate within-person, and compositional change in patient behavior and attitudes.Methods and measures: Over one year, 167 participants with type 2 diabetes and/or hypertension completed seven questionnaires assessing adherence perceptions (adherence, benefit, and burden), patient-practitioner experiences (alliance and confusion), close interpersonal interactions (positive and negative), and stress.

RESULTS

Multilevel structural equation modeling analyses revealed that nearly all hypothesized between-person associations were significant. Moreover, all hypothesized predictors explained within-person change in at least one adherence outcome. Predictors also produced compositional effects where outcomes were predicted by scores sustained over time. Most social and stress variables had unique associations with adherence perceptions after controlling for other predictors.

CONCLUSION

Results highlight the complexity of change processes and importance of social relationships and stress for adherence. Greater understanding of these processes may improve outcomes for individuals with type 2 diabetes and/or hypertension.

Identifying determinants of adherence to adjuvant endocrine therapy following breast cancer: A systematic review of reviews

BACKGROUND

In oestrogen-receptor positive breast cancer, daily oral adjuvant endocrine therapy (ET) for at least 5 years significantly reduces risks of recurrence and breast cancer-specific mortality. However, many women are poorly adherent to ET. Development of effective adherence support requires comprehensive understanding of influences on adherence. We undertook an umbrella review to identify determinants of ET adherence.

METHODS

We searched PubMed, Embase, CINAHL, PsycINFO, Cochrane and PROSPERO (inception to 08/2022) to identify systematic reviews on factors influencing ET adherence. Abstracted determinants were mapped to the World Health Organization's dimensions of adherence. Reviews were quality appraised and overlap assessed.

RESULTS

Of 5732 citations screened, 17 reviews were eligible (9 quantitative primary studies; 4 qualitative primary studies; 4 qualitative or quantitative studies) including 215 primary papers. All five WHO dimensions influenced ET non-adherence: The most consistently identified non-adherence determinants were patient-related factors (e.g. lower perceived ET necessity, more treatment concerns, perceptions of ET 'cons' vs. 'pros'). Healthcare system/healthcare professional-related factors (e.g. perceived lower quality health professional interaction/relationship) were also important and, to a somewhat lesser extent, socio-economic factors (e.g. lower levels of social/economic/material support). Evidence was more mixed for medication-related and condition-related factors, but several may be relevant (e.g. experiencing side-effects, cost). Potentially modifiable factors are more influential than non-modifiable/fixed factors (e.g. patient characteristics).

CONCLUSIONS

The evidence-base on ET adherence determinants is extensive. Future empirical studies should focus on less well-researched areas and settings. The determinants themselves are numerous and complex in indicating that adherence support should be multifaceted, addressing multiple determinants.

A cost-analysis of managing secondary and apparent treatment-resistant hypertension in a specialist multidisciplinary hypertension clinic

OBJECTIVES

A knowledge gap exists around the costs and budget impact of specialist hypertension clinics. This study reports on the cost of providing care in a multidisciplinary hypertension clinic staffed by nephrologist, endocrinologist and cardiologist, which manages patients with suspected secondary hypertension and/or apparent treatment-resistant hypertension. The aim of this study is to provide the evidence required to inform policy and planning care pathways for this patient group.

METHODS

A cost analysis from a healthcare provider perspective using micro-costing techniques was conducted to estimate the direct implementation costs of existing standard practice for the care pathway of patients attending the multidisciplinary hypertension clinic. Sixty-five patients originally recruited for a study of medication adherence in hypertension were included in the sample.

RESULTS

The total care-pathway cost per patient, taking into account clinic visits, clinical reviews, investigations and MDT discussion, was estimated to be €3277, on average. For the patient subgroups, the average cost was €5644 for patients diagnosed with primary aldosteronism and €1446 for patients diagnosed with essential hypertension.

CONCLUSION

There is significant cost associated with providing specialized hypertension care for patients with apparent treatment-resistant hypertension. Given the high rates of nonadherence in this population, it is likely that some of this cost could be avoided with better detection and management of medication adherence in this challenging population. Future studies should consider the cost-effectiveness of this or similar models of care by exploring the benefit to patients and the wider healthcare context of providing care of this type.

A Machine Learning Model to Predict Patients' Adherence Behavior and a Decision Support System for Patients With Metastatic Breast Cancer: Protocol for a Randomized Controlled Trial

BACKGROUND

Adherence to oral anticancer treatments is critical in the disease trajectory of patients with breast cancer. Given the impact of nonadherence on clinical outcomes and the associated economic burden for the health care system, finding ways to increase treatment adherence is particularly relevant.

OBJECTIVE

The primary end point is to evaluate the effectiveness of a decision support system (DSS) and a machine learning web application in promoting adherence to oral anticancer treatments among patients with metastatic breast cancer. The secondary end point is to collect a set of new physical, psychological, social, behavioral, and quality of life predictive variables that could be used to refine the preliminary version of the machine learning model to predict patients' adherence behavior.

METHODS

This prospective, randomized controlled study is nested in a large-scale international project named "Enhancing therapy adherence among metastatic breast cancer patients" (Pfizer 65080791), aimed to develop a predictive model of nonadherence and associated DSS and guidelines to foster patients' engagement and therapy adherence. A web-based DSS named TREAT (treatment adherence support) was developed using a patient-driven approach, with 4 sections, that is, Section A: Metastatic Breast Cancer; Section B: Adherence to Cancer Therapies; Section C: Promoting Adherence; and Section D: My Adherence Diary. Moreover, a machine learning-based web application was developed to predict patients' risk factors of adherence to anticancer treatment, specifically pertaining to physical status and comorbid conditions, as well as short and long-term side effects. Overall, 100 patients consecutively admitted at the European Institute of Oncology (IEO) at the Division of Medical Senology will be enrolled; 50 patients with metastatic breast cancer will be exposed to the DSS and machine learning web application for 3 months (experimental group), and 50 patients will not be exposed to the intervention (control group). Each participant will fill a weekly medication diary and a set of standardized self-reports evaluating psychological and quality of life variables (Adherence Attitude Inventory, Beck Depression Inventory-II, Brief Pain Inventory, 13-item Sense of Coherence scale, Brief Italian version of Cancer Behavior Inventory, European Organization for Research and Treatment of Cancer Quality of Life 23-item Breast Cancer-specific Questionnaire, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, 8-item Morisky Medication Adherence Scale, State-Trait Anxiety Inventory forms I and II, Big Five Inventory, and visual analogue scales evaluating risk perception). The 3 assessment time points are T0 (baseline), T1 (1 month), T2 (2 months), and T3 (3 months). This study was approved by the IEO ethics committee (R1786/22-IEO 1907).

RESULTS

The recruitment process started in May 2023 and is expected to conclude on December 2023.

CONCLUSIONS

The contribution of machine learning techniques through risk-predictive models integrated into DSS will enable medication adherence by patients with cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06161181; https://clinicaltrials.gov/study/NCT06161181.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48852.

Medications Non-adherence Reasoning Scale (MedNARS): Development and psychometric properties appraisal

Background

Proper elucidation of medication non-adherence reasoning especially in older adults might pave the way for an auspicious therapeutic outcome. The main aim of this study was to develop and psychometrically test the Medications Non-adherence Reasoning (MedNARS) questionnaire for application in research and probably practice settings.

Methods

A mixed methods design was utilized to develop the MedNARS. The item pool was mainly generated based on a qualitative query and literature review. The expert panel approved version of the MedNARS was psychometrically assessed on a convenience sample of 220 older patients with chronic disease. The internal consistency, test-retest reliability, content and face validity of the scale were appraised and its construct validity was assed using exploratory and confirmatory factor analyses.

Results

A nine-item version of the MedNARS was drafted based on the classical item analysis procedures and its estimated internal consistency measure of the Cronbach's alpha (0.85) and test-retest reliability (0.96) were in the vicinity of acceptable range. The exploratory factor analysis (EFA) output revealed a unidimensional structure for the MedNARS and the conducted confirmatory factor analysis (CFA) indicated an acceptable data fit for the extracted one-factor model. The goodness of fit indices were as the followings: χ2 /df=1.63(90% CI: 0.02 to 0.11), root mean squared error of approximation (RMSEA)=(0.07), comparative fit index (CFI)=0.95, Tucker-Lewis index (TLI)=0.93 and standardized root mean squared residual (SRMSR)=(0.05).

Conclusion

The study findings were indicative of MedNARS's applicability and feasibility for use in assessment of medication non-adherence reasoning among the elderly patients with chronic diseases. The MedNARS as a brief and elder-friendly instrument can be applied both in research and practice settings to enhance efficiency, safety, and health outcomes of the therapeutic recommendations.

Using an Intervention Mapping Approach to Improve Adherence to Disease-Modifying Treatment in Multiple Sclerosis

BACKGROUND

Up to 50% of individuals with multiple sclerosis (MS) who are prescribed disease-modifying treatments (DMTs) do not take them as advised. Although many studies report on DMT adherence rate, few studies report on interventions involving individuals with MS. The current paper describes the development of an intervention aimed at improving adherence to DMTs among identified nonadherent individuals with MS.

METHODS

An intervention was developed using an Intervention Mapping approach, recommendations from reviews on medication adherence, and input from individuals with MS. Its content was determined by theories of health behavior (specifically, a perceptions and practicalities approach), empirical evidence collected among the specific target population (an observational "needs assessment" stage [n = 186]), and other studies.

RESULTS

A personalized intervention was tailored to the reasons for nonadherence, uncovered during the observational needs assessment stage, to be delivered sequentially by a neurologist and a psychologist. After the intervention objectives were identified, components of the intervention were set: psychoeducation and ways of coping with adverse effects; modification of unhelpful treatment beliefs (such modifications were found predictive of adherence in the observational phase of the study); improving confidence and self-efficacy; and developing strategies for remembering to take DMTs. These components were embedded within motivational interviewing.

CONCLUSIONS

Intervention Mapping was useful in developing an intervention grounded both in the theoretical approach of perceptions and practicalities and in empirical evidence from the literature and the target sample; concurrently, identifying determinants that the intervention did not address. The effectiveness of the intervention-which could potentially improve adherence among individuals with MS-needs to be examined.

Supporting GPs and people with hypertension to maximise medication use to control blood pressure: Protocol for a pilot cluster RCT of the MIAMI intervention

Background: Hypertension is one of the most important risk factors for stroke and heart disease. Recent international guidelines have stated that 'poor adherence to treatment - in addition to physician inertia - is the most important cause of poor blood pressure control'. The MaxImising Adherence, Minimising Inertia (MIAMI) intervention, which has been developed using a systematic, theoretical, user-centred approach, aims to support general practitioners (GPs) and people with hypertension to maximise medication use, through the facilitation of adequate information exchange within consultations about long-term antihypertensive medication use and adherence skill development. The aim of the MIAMI pilot cluster randomised controlled trial (RCT) is to gather and analyse feasibility data to allow us to (1) refine the intervention, and (2) determine the feasibility of a definitive RCT. Methods: GP practices (n = 6) will be recruited and randomised to the intervention arm (n = 3) or usual care control arm (n = 3). Each practice will recruit 10 patient participants. For a patient to be eligible they must have a diagnosis of hypertension, be on two or more anti-hypertensive medications, must not be achieving recommended blood pressure levels, and be over the age of 65 years. Participants in the intervention arm will meet their GP and receive the MIAMI intervention twice over three months. Quantitative data collection will take place at baseline and three month follow up. A pilot health economic analysis and a qualitative sub-study will also be incorporated into the study. Discussion: This pilot cluster RCT of the MIAMI intervention will allow us to gather valuable acceptability and feasibility data to further refine the intervention so it optimally designed for both GP and patient use. In particular, the qualitative component will provide an insight into GP and patient experiences of using the intervention.

Relationship Between Medication Literacy and Beliefs Among Persons with Type 2 Diabetes Mellitus in Guangdong, China

Purpose

To establish the relationship between medication literacy and medication beliefs among persons with type 2 diabetes mellitus (T2DM).

Patients and methods

A cross-sectional survey of 246 patients with T2DM was conducted between April and November 2022 at a tertiary hospital in Dongguan City, Guangdong Province, China. Subsequently, these patients were administered the General Information Questionnaire, the Chinese version of Medication Literacy Assessment Scale, and the Chinese version of Beliefs about Medicines Questionnaire-Specific via survey.

Results

The medication literacy score of patients with T2DM was 7.82±3.007, and the medication beliefs score was 2.26±4.011. The Pearson correlation analysis revealed a statistically significant but weakly positive correlation (r = 0.271, P < 0.001) between medication literacy and beliefs among patients diagnosed with T2DM. However, there was no significant correlation found between medication literacy and necessity (r = -0.021, P > 0.05), while a lowly negative correlation was observed between medication literacy and concerns (r = -0.307, P < 0.001). Moreover, the multiple linear regression analysis indicated that medication literacy, age, education level, and duration of medication usage were all significant factors influencing patients' medication beliefs (all P < 0.05). Together, these variables accounted for 15.3% of the total variance observed in the regression equation.

Conclusion

The study found a positive correlation between medication literacy and beliefs, and a negative correlation between medication literacy and concerns. These results indicate that enhancing medication literacy can improve medication adherence among individuals with T2DM by reducing concerns and strengthening medication beliefs.

Development of the HT&Me intervention to support women with breast cancer to adhere to adjuvant endocrine therapy and improve quality of life

BACKGROUND

Breast cancer is the most common cancer in women worldwide. Approximately 80% of breast cancers are oestrogen receptor positive (ER+). Patients treated surgically are usually recommended adjuvant endocrine therapy (AET) for 5-10 years. AET significantly reduces recurrence, but up to 50% of women do not take it as prescribed.

OBJECTIVE

To co-design and develop an intervention to support AET adherence and improve health-related quality-of-life (QoL) in women with breast cancer.

METHODS

Design and development of the HT&Me intervention took a person-based approach and was guided by the Medical Research Council framework for complex interventions, based on evidence and underpinned by theory. Literature reviews, behavioural analysis, and extensive key stakeholder involvement informed 'guiding principles' and the intervention logic model. Using co-design principles, a prototype intervention was developed and refined.

RESULTS

The blended tailored HT&Me intervention supports women to self-manage their AET. It comprises initial and follow-up consultations with a trained nurse, supported with an animation video, a web-app and ongoing motivational 'nudge' messages. It addresses perceptual (e.g. doubts about necessity, treatment concerns) and practical (e.g. forgetting) barriers to adherence and provides information, support and behaviour change techniques to improve QoL. Iterative patient feedback maximised feasibility, acceptability, and likelihood of maintaining adherence; health professional feedback maximised likelihood of scalability.

CONCLUSIONS

HT&Me has been systematically and rigorously developed to promote AET adherence and improve QoL, and is complemented with a logic model documenting hypothesized mechanisms of action. An ongoing feasibility trial will inform a future randomised control trial of effectiveness and cost-effectiveness.

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.

Informing interventions to improve uptake of adjuvant endocrine therapy in women with breast cancer: a theoretical-based examination of modifiable influences on non-adherence

PURPOSE

To inform intervention development, we measured the modifiable determinants of endocrine therapy (ET) non-adherence in women with breast cancer, using the Theoretical Domains Framework (TDF) and examined inter-relationships between these determinants and non-adherence using the Perceptions and Practicalities Approach (PAPA).

METHODS

Women with stages I-III breast cancer prescribed ET were identified from the National Cancer Registry Ireland (N = 2423) and invited to complete a questionnaire. A theoretically based model of non-adherence was developed using PAPA to examine inter-relationships between the 14 TDF domains of behaviour change and self-reported non-adherence. Structural equation modelling (SEM) was used to test the model.

RESULTS

A total of 1606 women participated (response rate = 66%) of whom 395 (25%) were non-adherent. The final SEM with three mediating latent variables (LVs) (PAPA Perceptions: TDF domains, Beliefs about Capabilities, Beliefs about Consequences; PAPA Practicalities: TDF domain, Memory, Attention, Decision Processes and Environment) and four independent LVs (PAPA Perceptions: Illness intrusiveness; PAPA Practicalities: TDF domains, Knowledge, Behaviour Regulation; PAPA External Factors: TDF domain, Social Identity) explained 59% of the variance in non-adherence and had an acceptable fit (χ²(334) = 1002, p < 0.001; RMSEA = 0.03; CFI = 0.96 and SRMR = 0.07) Knowledge had a significant mediating effect on non-adherence through Beliefs about Consequences and Beliefs about Capabilities. Illness intrusiveness had a significant mediating effect on non-adherence through Beliefs about Consequences. Beliefs about Consequences had a significant mediating effect on non-adherence through Memory, Attention, Decision Processesg and Environment.

CONCLUSIONS

By underpinning future interventions, this model has the potential to improve ET adherence and, hence, reduce recurrence and improve survival in breast cancer.

Medication beliefs, adherence, and outcomes in people with asthma: The importance of treatment beliefs in understanding inhaled corticosteroid nonadherence-a retrospective analysis of a real-world data set

Background

Poor adherence to inhaled corticosteroids (ICSs) increases asthma morbidity and mortality and is influenced by patients' treatment beliefs. This study maps patients' beliefs about ICSs across 6 countries examining variations in beliefs, and their relationship with adherence and outcomes.

Objective

We sought to explore the relationship between patient treatment beliefs, and adherence and outcomes in asthma across 6 countries.

Methods

Patients 18 years or older with asthma, receiving ICS alone or in combination with a long-acting β2-agonist, were included from a point-in-time paper survey of patients with asthma in Europe and the United States. Clinical characteristics, such as adherence and asthma control, were collected by self- and physician-report. Patients completed the Beliefs about Medicines Questionnaire, adapted for ICSs. Relationships between patient treatment beliefs, adherence, and outcomes were examined using regression analyses.

Results

Data from 1312 patients were analyzed. Patients were from Germany (24%), the United States (21%), France (21%), Spain (16%), Italy (10%), and the United Kingdom (9%). Most had physician-reported mild-intermittent asthma (87%), and mean age was 40 ± 15.5 years. There was considerable variation in necessity beliefs between countries, with respondents in Italy having more doubts about treatment necessity and respondents in Spain showing higher concerns. Patients with doubts about ICS necessity and high concerns had lower self-reported (necessity: χ2(2) = 34.31, P < .001; concerns: χ2(2) = 20.98, P < .001) and physician-reported adherence (necessity: χ2(2) = 11.70, P = .003; concerns: χ2(2) = 34.45, P < .001). Patients with high necessity beliefs (F(2, 483) = 3.33; P = .037) and high concerns (F(2,483) = 23.46; P < .001) reported poorer control. Physician estimates of adherence did not correlate well with patient self-report (ρ = 0.178, P < .001).

Conclusions

ICS necessity beliefs and concerns were associated with adherence and asthma control. This has implications for the design of adherence interventions.

Development and validation of a new non-disease-specific survey tool to assess self-reported adherence to medication

Background: Patients' non-adherence to medication affects both patients themselves and healthcare systems. Consequences include higher mortality, worsening of disease, patient injuries, and increased healthcare costs. Many existing survey tools for assessing adherence are linked to specific diseases and assessing medication-taking behavior or identifying barriers or beliefs. This study aimed to develop and validate a new non-disease-specific survey tool to assess self-reported medication-taking behavior, barriers, and beliefs in order to quantify the causes of non-adherence and measure adherence. Methods: The survey tool was developed after literature searches and pilot testing. Validation was conducted by assessing the psychometric properties of content, construct, reliability, and feasibility. Content validity was assessed by subject matter experts and construct validity by performing exploratory factor analysis. Reliability assessment was performed by calculating internal consistency, Cronbach's alpha and test/retest reliability, intraclass correlation coefficient (ICC), and standard error of measurement (SEm). A receiver operating characteristic (ROC) curve and the Lui method were used to calculate the statistical cut-off score for good versus poor adherence. Survey responses from Norwegian medication users over 18 years recruited via social media were used for the factor analysis and Cronbach's alpha. Results: The final survey tool contains 37 causes of non-adherence connected to medication-taking behavior and barriers to adherence and beliefs associated with adherence. The overall result for all 37 items demonstrated reliable internal consistency, Cronbach's alpha = 0.91. The factor analysis identified ten latent variables for 29 items, explaining 61.7% of the variance. Seven of the latent variables showed reliable internal consistency: medication fear and lack of effect, conditional practical issues, pregnancy/breastfeeding, information issues, needlessness, lifestyle, and avoiding stigmatization (Cronbach's alpha = 0.72-0.86). Shortage showed low internal consistency (Cronbach's alpha = 0.59). Impact issues and personal practical issues showed poor internal consistency (Cronbach's alpha = 0.51 and 0.48, respectively). The test/retest reliability ICC = 0.89 and SEm = 1.11, indicating good reliability. The statistical cut-off score for good versus poor adherence was 10, but the clinical cut-off score was found to be 2. Conclusion: This survey tool, OMAS-37 (OsloMet Adherence to medication Survey tool, 37 items), demonstrated to be a valid and reliable instrument for assessing adherence. Further studies will examine the ability of the tool for measuring adherence enhancing effect following interventions.

Effective Communication and the Osteoporosis Care Gap

Many pharmacological treatments are now available to prevent the occurrence of fragility fractures in patients with osteoporosis. Despite this, concerns persist that many individuals who might benefit from osteoporosis treatment do not receive it-the "osteoporosis treatment gap." The underlying reasons for this gap are diverse and include those who are not identified as being eligible for treatment as well as those who intentionally choose not to take medications because of uncertainty, unanswered questions, or an inability to understand or do what is being asked of them. In this perspective article we highlight the importance of providing information on the causes and consequences of osteoporosis during encounters when treatment is being discussed as well as what osteoporosis treatment can achieve and what it cannot. We also review the importance of communicating the benefits and risks of treatment in absolute terms so that patients can understand what taking treatment will mean for them and discuss the utility of decision aids to assist in these conversations. We suggest it is not the treatment gap that is the problem but the care gap. This language acknowledges the importance of healthcare providers identifying those likely to benefit from treatment and increasing the quality of clinical conversations to promote patient engagement and involvement while respecting that treatment is not suitable or wanted by all. © 2022 American Society for Bone and Mineral Research (ASBMR).

Supporting patients to get the best from their osteoporosis treatment: a rapid realist review of what works, for whom, and in what circumstance

Systematic reviews that examine effectiveness of interventions to improve medicines optimisation do not explain how or why they work. This realist review identified that interventions which effectively optimise medicines use in osteoporosis include opportunities to address patients' perceptions of illness and treatment and/or support primary care clinician decision making.

INTRODUCTION

In people with osteoporosis, adherence to medicines is poorer than other diseases and patients report follow-up is lacking, and multiple unmet information needs. We conducted a rapid realist review to understand what contextual conditions and mechanisms enable interventions to support osteoporosis medication optimisation.

METHODS

A primary search identified observational or interventional studies which aimed to improve medicines adherence or optimisation; a supplementary second search identified research of any design to gain additional insights on emerging findings. Extracted data was interrogated for patterns of context-mechanism-outcome configurations, further discussed in team meetings, informed by background literature and the Practicalities and Perception Approach as an underpinning conceptual framework.

RESULTS

We identified 5 contextual timepoints for the person with osteoporosis (identifying a problem; starting medicine; continuing medicine) and the practitioner and healthcare system (making a diagnosis and giving a treatment recommendation; reviewing medicine). Interventions which support patient-informed decision making appear to influence long-term commitment to treatment. Supporting patients' practical ability to adhere (e.g. by lowering treatment burden and issuing reminders) only appears to be helpful, when combined with other approaches to address patient beliefs and concerns. However, few studies explicitly addressed patients' perceptions of illness and treatment. Supporting primary care clinician decision making and integration of primary and secondary care services also appears to be important, in improving rates of treatment initiation and adherence.

CONCLUSIONS

We identified a need for further research to identify a sustainable, integrated, patient-centred, and cost- and clinically effective model of long-term care for people with osteoporosis.

A systematic review of the barriers and facilitators to adherence to mindfulness‐based cognitive therapy for those with chronic conditions

PURPOSE

Mindfulness-Based Cognitive Therapy (MBCT) can improve the lives of those with a chronic condition and psychological distress, however, high drop-out rates limit benefits. MBCT might be a candidate treatment for this population if nonadherence can be overcome. This review explores the existing literature on the barriers and facilitators to adherence to MBCT for those with chronic conditions.

METHOD

Databases MEDLINE, PsycINFO, CINAHL and Scopus were searched between 28^th May and 11th June 2021. We included empirical papers that identified barriers and/or facilitators to MBCT adherence in patients with chronic conditions-excluding non-English and grey literature. Papers were screened and duplicates removed. Extracted data included: setting, design, aim, sample-size, population and identified barriers/facilitators to MBCT adherence. The Mixed Methods Appraisal Tool (MMAT) was adapted and used to appraise the quality of studies RESULTS: Twenty papers were eligible for review. Synthesis identified six themes (in prevalence order): (1) Practical Factors (e.g., time and other commitments), (2) Motivation (e.g., change-readiness), (3) Patient clinical and demographic characteristics (e.g., current physical health), (4) Connection with Others (facilitators and group members), (5) Credibility (perception of the intervention) and (6) Content difficulty (intervention accessibility). Findings highlight potential adaptations to implementation (e.g., clear treatment rationale, preference matching, and eliciting and responding to individual concerns or obstructive assumptions) that could address barriers and harness facilitators.

CONCLUSION

This review contributes a higher order understanding of factors that may support/obstruct client adherence to MBCT with implications for future implementation in research and practice. Future research should prioritize open exploration of barriers/facilitators.

Neuroticism and Conscientiousness Moderate the Effect of Oral Medication Beliefs on Adherence of People with Mental Illness during the Pandemic

Background. After the declaration of the pandemic status in several countries, the continuity of face-to-face visits in psychiatric facilities has been delayed or even interrupted to reduce viral spread. Little is known about the personality factors associated with medication beliefs and adherence amongst individuals with mental illness during the COVID-19 pandemic. This brief report describes a preliminary naturalistic longitudinal study that explored whether the Big Five personality traits prospectively moderate the effects of medication beliefs on changes in adherence during the pandemic for a group of outpatients with psychosis or bipolar disorder. Methods. Thirteen outpatients undergoing routine face-to-face follow-up assessments during the pandemic were included (41 observations overall) and completed the Revised Italian Version of the Ten-Item Personality Inventory, the Beliefs about Medicines Questionnaire, the Morisky Medication Adherence Scale—8-item and the Beck Depression Inventory—II. Results. Participants had stronger concerns about their psychiatric medications rather than beliefs about their necessity, and adherence to medications was generally low. Participants who had more necessity beliefs than concerns had better adherence to medications. People scoring higher in Conscientiousness and Neuroticism traits and more concerned about the medication side effects had poorer adherence. Conclusions. These preliminary data suggest the importance of a careful assessment of the adherence to medications amongst people with psychosis/bipolar disorder during the pandemic. Interventions aimed to improve adherence might focus on patients’ medication beliefs and their Conscientiousness and Neuroticism personality traits.

Evaluating the effect of short-course rifapentine-based regimens with or without enhanced behaviour-targeted treatment support on adherence and completion of treatment for latent tuberculosis infection among adults in the UK (RID-TB: Treat): protocol for an open-label, multicentre, randomised controlled trial

INTRODUCTION

The successful scale-up of a latent tuberculosis (TB) infection testing and treatment programme is essential to achieve TB elimination. However, poor adherence compromises its therapeutic effectiveness. Novel rifapentine-based regimens and treatment support based on behavioural science theory may improve treatment adherence and completion.

METHODS AND ANALYSIS

A pragmatic multicentre, open-label, randomised controlled trial assessing the effect of novel short-course rifapentine-based regimens for TB prevention and additional theory-based treatment support on treatment adherence against standard-of-care. Participants aged between 16 and 65 who are eligible to start TB preventive therapy will be recruited in England. 920 participants will be randomised to one of six arms with allocation ratio of 5:5:6:6:6:6: daily isoniazid +rifampicin for 3 months (3HR), routine treatment support (control); 3HR, additional treatment support; weekly isoniazid +rifapentine for 3 months (3HP), routine treatment support; weekly 3HP, additional treatment support ; daily isoniazid +rifapentine for 1 month (1HP), routine treatment support; daily 1HP, additional treatment support. Additional treatment support comprises reminders using an electronic pillbox, a short animation, and leaflets based on the perceptions and practicalities approach. The primary outcome is adequate treatment adherence, defined as taking ≥90% of allocated doses within the pre-specified treatment period, measured by electronic pillboxes. Secondary outcomes include safety and TB incidence within 12 months. We will conduct process evaluation of the trial interventions and assess intervention acceptability and fidelity and mechanisms for effect and estimate the cost-effectiveness of novel regimens. The protocol was developed with patient and public involvement, which will continue throughout the trial.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from The National Health Service Health Research Authority (20/LO/1097). All participants will be required to provide written informed consent. We will share the results in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

EudraCT 2020-004444-29.

Digital interventions to improve adherence to maintenance medication in asthma

BACKGROUND

Asthma is the most common chronic lung condition worldwide, affecting 334 million adults and children globally. Despite the availability of effective treatment, such as inhaled corticosteroids (ICS), adherence to maintenance medication remains suboptimal. Poor ICS adherence leads to increased asthma symptoms, exacerbations, hospitalisations, and healthcare utilisation. Importantly, suboptimal use of asthma medication is a key contributor to asthma deaths. The impact of digital interventions on adherence and asthma outcomes is unknown.

OBJECTIVES

To determine the effectiveness of digital interventions for improving adherence to maintenance treatments in asthma.

SEARCH METHODS

We identified trials from the Cochrane Airways Trials Register, which contains studies identified through multiple electronic searches and handsearches of other sources. We also searched trial registries and reference lists of primary studies. We conducted the most recent searches on 1 June 2020, with no restrictions on language of publication. A further search was run in October 2021, but studies were not fully incorporated.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) including cluster- and quasi-randomised trials of any duration in any setting, comparing a digital adherence intervention with a non-digital adherence intervention or usual care. We included adults and children with a clinical diagnosis of asthma, receiving maintenance treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures for data collection. We used GRADE to assess quantitative outcomes where data were available.

MAIN RESULTS

We included 40 parallel randomised controlled trials (RCTs) involving adults and children with asthma (n = 15,207), of which eight are ongoing studies. Of the included studies, 30 contributed data to at least one meta-analysis. The total number of participants ranged from 18 to 8517 (median 339). Intervention length ranged from two to 104 weeks. Most studies (n = 29) reported adherence to maintenance medication as their primary outcome; other outcomes such as asthma control and quality of life were also commonly reported. Studies had low or unclear risk of selection bias but high risk of performance and detection biases due to inability to blind the participants, personnel, or outcome assessors. A quarter of the studies had high risk of attrition bias and selective outcome reporting. We examined the effect of digital interventions using meta-analysis for the following outcomes: adherence (16 studies); asthma control (16 studies); asthma exacerbations (six studies); unscheduled healthcare utilisation (four studies); lung function (seven studies); and quality of life (10 studies). Pooled results showed that patients receiving digital interventions may have increased adherence (mean difference of 14.66 percentage points, 95% confidence interval (CI) 7.74 to 21.57; low-certainty evidence); this is likely to be clinically significant in those with poor baseline medication adherence. Subgroup analysis by type of intervention was significant (P = 0.001), with better adherence shown with electronic monitoring devices (EMDs) (23 percentage points over control, 95% CI 10.84 to 34.16; seven studies), and with short message services (SMS) (12 percentage points over control, 95% CI 6.22 to 18.03; four studies). No significant subgroup differences were seen for interventions having an in-person component versus fully digital interventions, adherence feedback, one or multiple digital components to the intervention, or participant age. Digital interventions were likely to improve asthma control (standardised mean difference (SMD) 0.31 higher, 95% CI 0.17 to 0.44; moderate-certainty evidence) - a small but likely clinically significant effect. They may reduce asthma exacerbations (risk ratio 0.53, 95% CI 0.32 to 0.91; low-certainty evidence). Digital interventions may result in a slight change in unscheduled healthcare utilisation, although some studies reported no or a worsened effect. School or work absence data could not be included for meta-analysis due to the heterogeneity in reporting and the low number of studies. They may result in little or no difference in lung function (forced expiratory volume in one second (FEV1)): there was an improvement of 3.58% predicted FEV1, 95% CI 1.00% to 6.17%; moderate-certainty evidence); however, this is unlikely to be clinically significant as the FEV1 change is below 12%. Digital interventions likely increase quality of life (SMD 0.26 higher, 95% CI 0.07 to 0.45; moderate-certainty evidence); however, this is a small effect that may not be clinically significant. Acceptability data showed positive attitudes towards digital interventions. There were no data on cost-effectiveness or adverse events. Our confidence in the evidence was reduced by risk of bias and inconsistency.

AUTHORS' CONCLUSIONS

Overall, digital interventions may result in a large increase in adherence (low-certainty evidence). There is moderate-certainty evidence that digital adherence interventions likely improve asthma control to a degree that is clinically significant, and likely increase quality of life, but there is little or no improvement in lung function. The review found low-certainty evidence that digital interventions may reduce asthma exacerbations. Subgroup analyses show that EMDs may improve adherence by 23% and SMS interventions by 12%, and interventions with an in-person element and adherence feedback may have greater benefits for asthma control and adherence, respectively. Future studies should include percentage adherence as a routine outcome measure to enable comparison between studies and meta-analysis, and use validated questionnaires to assess adherence and outcomes.

The Association between Psychosocial and Age-Related Factors with Adherence to Immunosuppressive Therapies after Renal Transplantation

Renal transplantation (RT) is the optimal renal replacement treatment approach in terms of patient survival and high quality of life. Proper adherence to medication is essential in order to prolong graft life and patient survival. This study aimed to investigate the effects of psychosocial factors and age-related declines on adherence in kidney transplant recipients. Methods: This was a cross-sectional study of kidney transplant recipients, based on regression analysis. Patient adherence was assessed with the Basel Assessment of Adherence with Immunosuppressive Medication Scale (BAASIS). Psychosocial and age-related variables were measured with the World Health Organization’s quality of life questionnaire (WHOQoL-BREF), the Mini-Mental State Examination (MMSE), the Hospital Anxiety and Depression Scale (HADS), the Acceptance of Illness Scale (AIS), and the Tilburg Frailty Indicator (TFI). Results: A simple linear regression model indicated that the significant predictors of self-reported adherence (p < 0.05) were age, time since transplant, and anxiety and cognitive functions. For problems with implementing immunosuppressive medication, logistic regression models showed that gender, age, retirement status, hypercholesterolemia, and cognitive impairment were the most significant predictors (p < 0.05). However, after controlling for other predictors in the multiple regression models, anxiety and cognitive ability no longer predicted treatment adherence to immunosuppressive medication. Conclusions: Renal transplantation is the most effective therapy in chronic renal failure patients. Proper adherence to immunosuppressive therapy is critical to prolonging graft and person survival. Our study shows that occupational status more significantly influences adherence to the implementation of treatment in kidney transplant recipients.

Features of successful interventions to improve adherence to inhaled corticosteroids in children with asthma: A narrative systematic review

INTRODUCTION

Nonadherence to inhaled corticosteroids (ICSs) in children with asthma leads to significant morbidity and mortality. Few adherence interventions have been effective and little is known about what contributes to intervention effectiveness. This systematic review summarizes the efficacy and the characteristics of effective interventions.

METHODS

Six databases were systematically searched on October 3, 2020 for randomized control trials measuring adherence to ICS in children with asthma. A narrative synthesis was conducted focusing on intervention efficacy and study reliability. Intervention content was coded based on the National Institute for Health and Care Excellence guidelines for medicines adherence (the Perceptions and Practicalities Approach, PAPA) and behavior change techniques (BCTs), to determine the effective aspects of the intervention.

RESULTS

Of 240 studies identified, 25 were eligible for inclusion. Thirteen of the 25 studies were categorized as being highly reliable. Nine of the 13 interventions were effective at increasing adherence and 6 of those met the criteria for a PAPA intervention. Techniques targeting perceptions and practicalities in successful interventions included rewards, reminders, feedback and monitoring of adherence, pharmacological support, instruction on how to take their ICS/adhere, and information about triggers for symptoms and nonadherence.

CONCLUSION

Adherence interventions in children with asthma have mixed effectiveness. Effective intervention studies were more frequently of higher quality, were tailored to individuals' perceptual and practical adherence barriers, and used multiple BCTs. However, due to the small number of included studies and varying study design quality, conclusions drawn here are preliminary. Future research is needed to test a PAPA-based intervention with a rigorous study design.

Medication-taking for secondary prevention of acute myocardial infarction: a thematic meta-synthesis of patient experiences

Objective

To collate existing qualitative research examining patients’ medication-taking experiences in secondary prevention of acute myocardial infarction (AMI) and produce new knowledge, a systematic review and meta-synthesis of patient qualitative studies was conducted.

Method

A systematic review found nine reports suitable for inclusion. Themes found by the report authors and report characteristic data were extracted. Reports were assessed for quality. A meta-synthesis using thematic coding and constant comparison method produced higher order themes, and these were used to construct a statement organised by theme using specific examples from the included studies.

Results

All patients discussed their medication-taking in thematic categories of beliefs about medication and illness, personal ability and interpersonal factors. Themes differed between classes of medication and between patients, suggesting tailored interventions to medications and individual patients would be appropriate. Some themes overlapped with those discussed by the broader group of cardiovascular patients, but some themes were unique to this myocardial infarction patient group, again indicating that a tailored approach is appropriate for this patient group.

Conclusion

The themes of beliefs about medication and illness, personal ability and interpersonal support provide tangible starting points for addressing adherence issues. The concept of medication-taking had unique elements within the post-AMI group of patients, and between classes of medication. While these themes were grouped into more generalised higher-order constructs, there were differences between patients within the themed group, indicating that themes are useful as a guide, but individual-level patient support is appropriate.

Patient and practitioner views on a combined face-to-face and digital intervention to support medication adherence in hypertension: a qualitative study within primary care

OBJECTIVES

To explore patients' and healthcare practitioners' (HCPs) views about non-adherence to hypertension medication and potential content of a combined very brief face-to-face discussion (VBI) and digital intervention (DI).

METHODS

A qualitative study (N=31): interviews with patients with hypertension (n=6) and HCPs (n=11) and four focus groups with patients with hypertension (n=14). Participants were recruited through general practices in Eastern England and London. Topic guides explored reasons for medication non-adherence and attitudes towards a potential intervention to support adherence. Stimuli to facilitate discussion included example SMS messages and smartphone app features, including mobile sensing. Analysis was informed methodologically by the constant comparative approach and theoretically by perceptions and practicalities approach.

RESULTS

Participants' overarching explanations for non-adherence were non-intentional (forgetting) and intentional (concerns about side effects, reluctance to medicate). These underpinned their views on intervention components: messages that targeted forgetting medication or obtaining prescriptions were considered more useful than messages providing information on consequences of non-adherence. Tailoring the DI to the individuals' needs, regarding timing and number of messages, was considered important for user engagement. Patients wanted control over the DI and information about data use associated with any location sensing. While the DI was considered limited in its potential to address intentional non-adherence, HCPs saw the potential for a VBI in addressing this gap, if conducted in a non-judgemental manner. Incorporating a VBI into routine primary care was considered feasible, provided it complemented existing GP practice software and HCPs received sufficient training.

CONCLUSIONS

A combined VBI-DI can potentially address intentional and non-intentional reasons for non-adherence to hypertension medication. For optimal engagement, recommendations from this work include a VBI conducted in a non-judgmental manner and focusing on non-intentional factors, followed by a DI that is easy-to-use, highly tailored and with provision of data privacy details about any sensing technology used.

Perceptions and Practicalities Influencing Pre-exposure Prophylaxis Adherence Among Men Who Have Sex with Men in England

PrEP is highly effective for HIV prevention but requires adequate adherence. In this paper we use the perceptions and practicalities approach (PAPA) to identify factors that influenced PrEP adherence using qualitative data from the PROUD study. From February 2014 to January 2016, we interviewed 41 gay, bisexual and other men-who-have-sex-with-men and one trans woman who were enrolled in the study. We purposively recruited participants for interview based on trial arm allocation, adherence and sexual risk behaviours. The interviews were conducted in English, audio-recorded, transcribed, coded and analysed using framework analysis. Participants in general were highly motivated to use and adhere to PrEP, and this was linked to strong perceptions of personal necessity for PrEP as they felt at risk of HIV and viewed PrEP as highly effective. On the other hand, concerns about side effects and HIV resistance did inhibit PrEP initiation and adherence although this was uncommon. Practical factors such as daily routine, existing habitual pill-taking and pill storage impacted adherence. Drug and alcohol use rarely caused participants to miss doses. These findings indicate that using the principals of PAPA to unpick influencers of PrEP use, could help tailor adherence support in PrEP programmes.

Beliefs about medication after hospital discharge in geriatric patients with polypharmacy

OBJECTIVES

To describe beliefs about medication in geriatric patients with polypharmacy post-discharge and to evaluate the impact of discharge management on patients' medication beliefs.

METHODS

A cross-sectional study was conducted between November 2019 and March 2020 in twelve general hospitals in Belgium. Four hundred geriatric patients with polypharmacy were surveyed at hospital discharge and two to five days post-discharge using the Beliefs about Medicines Questionnaire and self-developed questionnaires.

RESULTS

According to participants, the benefits of medication outweighed the disadvantages as the mean necessity score (19.4/25) outweighed the mean concern score (11.9/25). Patients receiving help with medication management post-discharge had stronger necessity-, concern- and overuse-related beliefs. No patient- or discharge management-related factors were significant predictors of medication beliefs.

CONCLUSIONS

Assessing patients' medication beliefs and identifying and addressing patients' concerns, can be an opportunity to improve medication use, to prevent non-adherence and to enhance safe medication practices at home.

Determining factors associated with inhaled therapy adherence on asthma and COPD: A systematic review and meta-analysis of the global literature

BACKGROUND

Adherence to therapy has been reported worldwide as a major problem, and that is particularly relevant on inhaled therapy for Asthma and Chronic Obstructive Pulmonary Disease (COPD), considering its barriers and features. We reviewed the global literature reporting the main determinants for adherence on these patients.

METHODS

Searches were made using the Cochrane Library, MEDLINE, EMBASE and ISI Web of Science databases. Analytical, observational and epidemiological studies (cohort, case-control and cross-sectional studies) were included, reporting association between any type of determinant and the adherence for inhaler therapy on Asthma or COPD. Random-effects meta-analysis were used to summarise the numerical effect estimates.

RESULTS

47 studies were included, including a total of 54.765 participants. In meta-analyses, the significant determinants of adherence to inhaled therapy were: older age [RR = 1.07 (1.03-1.10); I² = 94; p < 0.0001] good disease knowledge/literacy [RR = 1.37 (1.28-1.47); I² = 14; p = 0.33]; obesity [RR = 1.30 (1.12-1.50); I² = 0; p = 0.37]; good cognitive performance [RR = 1.28 (1.17-1.40); I² = 0; p = 0.62]; higher income [RR = 1.63 (1.05-2.56); I² = 0; p = 0.52]; being employed [RR = 0.87 (0.83-0.90); I² = 0; p = 0.76] and using multiple drugs/inhalers [RR = 0.81 (0.79-0.84); I² = 0; p = 0.80]. Overall, the strength of the underlying evidence was only low to moderate.

CONCLUSIONS

Many determinants may be associated to patient's adherence, and personalised interventions should be taken in clinical practice to address it by gaining an understanding of their individual features.

A phenomenological analysis of the experience of taking medication to prevent a further heart attack

Following an acute myocardial infarction, patients are prescribed a regime of cardio-protective medication to prevent recurrent cardiovascular events and mortality. Adherence to medication is poor in this patient group, and not fully understood. Current interventions have made limited improvements but are based upon presumed principles. To describe the phenomenon of medicine-taking for an individual taking medication for secondary prevention for an AMI, Interpretative Phenomenological Analysis was used to analyse transcripts of semi-structured interviews with participants. Themes were generated for each participant, then summarized across participants. Five key themes were produced; the participants needed to compare themselves to others, showed that knowledge of their medicines was important to them, discussed how the future was an unknown entity for them, had assimilated their medicines into their lives, and expressed how an upset to their routine reduced their ability to take medication. Participants described complex factors and personal adaptations to taking their medication. This suggests that a patient-centred approach is appropriate for adherence work, and these themes could inform clinical practice to better support patients in their medicine adherence.

Effectiveness of mobile health interventions to improve nasal corticosteroid adherence in allergic rhinitis: A systematic review

BACKGROUND

Mobile health interventions (MHI) offer the potential to help improve nasal corticosteroid (NCS) adherence in allergic rhinitis (AR). The aim of this systematic review was to summarise the current evidence on the effectiveness of MHI for improving NCS adherence in AR.

METHODS

We systematically searched MEDLINE, Embase and the Cochrane Central register of Controlled Trials (CENTRAL) for randomised controlled trials filtered for publication dates between 2010 and 2021. We evaluated the effects of MHI aiming to improve NCS adherence on self-management outcomes in AR and comorbid conditions. Two reviewers independently screened potential studies, extracted study characteristics and outcomes from eligible papers and assessed risk of bias using the Cochrane Risk of Bias tool 2.0. High heterogeneity precluded meta-analysis. Data were descriptively and narratively synthesised.

RESULTS

Our searches identified 776 individual studies of which 4 met the inclusion criteria. These studies were heterogeneous with respect to participant, intervention and outcome characteristics. We considered all outcome-specific overall risk of bias assessments to be of high risk of bias except for two studies examining NCS adherence which received 'some concern' grades. The three studies which reported on NCS adherence found that MHI were associated with improvement in NCS adherence. Significant MHI-associated improvement in symptoms or disease-specific quality of life was found in one study each, whilst no study reported significant differences in nasal patency.

CONCLUSIONS

Whilst MHI showed potential to improve NCS adherence, their effect on clinical outcomes varied. Furthermore, robust studies with longer intervention durations are needed to adequately assess effects of MHI and their individual features on NCS adherence and clinical outcomes.

Evaluation of quality and readability of online patient information on osteoporosis and osteoporosis drug treatment and recommendations for improvement

Patient information is important to help patients fully participate in their healthcare. Commonly accessed osteoporosis patient information resources were identified and assessed for readability, quality, accuracy and consistency. Resources contained inconsistencies and scored low when assessed for quality and readability. We recommend optimal language and identify information gaps to address.

INTRODUCTION

The purpose of this paper is to identify commonly accessed patient information resources about osteoporosis and osteoporosis drug treatment, appraise the quality and make recommendations for improvement.

METHODS

Patient information resources were purposively sampled and text extracted. Data extracts underwent assessment of readability (Flesch Reading Ease and Flesch-Kincaid Grade Level) and quality (modified International Patient Decision Aid Standards (m-IPDAS)). A thematic analysis was conducted, and keywords and phrases were used to describe osteoporosis and its treatment identified. Findings were presented to a stakeholder group who identified inaccuracies and contradictions and discussed optimal language.

RESULTS

Nine patient information resources were selected, including webpages, a video and booklets (available online), from government, charity and private healthcare providers. No resource met acceptable readability scores for both measures of osteoporosis information and drug information. Quality scores from the modified IPDAS ranged from 21 to 64% (7-21/33). Thematic analysis was informed by Leventhal's Common-Sense Model of Disease. Thirteen subthemes relating to the identity, causes, timeline, consequences and controllability of osteoporosis were identified. Phrases and words from 9 subthemes were presented to the stakeholder group who identified a predominance of medical technical language, misleading terms about osteoporotic bone and treatment benefits, and contradictions about symptoms. They recommended key descriptors for providers to use to describe osteoporosis and treatment benefits.

CONCLUSIONS

This study found that commonly accessed patient information resources about osteoporosis have highly variable quality, scored poorly on readability assessments and contained inconsistencies and inaccuracies. We produced practical recommendations for information providers to support improvements in understanding, relevance, balance and bias, and to address information gaps.

Electronic adherence monitoring devices for children with asthma: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Asthma is a common chronic condition amongst children. Poor adherence to asthma medications can increase asthma exacerbations, absence from school, healthcare utilisation and costs and decrease quality of life. Emerging evidence suggests the use of electronic adherence monitoring devices in improving children's adherence to medications.

OBJECTIVES

This study aimed to evaluate the effectiveness of electronic adherence monitoring devices in improving inhaler adherence amongst children with asthma.

DESIGN

This study is a systematic review and meta-analysis.

DATA SOURCES

A systematic search using Cochrane Library, PubMed, Embase, CINAHL, Web of Science, Scopus and ProQuest Dissertations and Theses from inception up to April 6, 2021, was conducted.

REVIEW METHODS

Randomised controlled trials evaluating the use of electronic adherence monitoring devices amongst children and published in English were included. The outcomes were inhaler adherence, asthma exacerbation, lung function, asthma control and accessibility. The overall effect was measured using Hedges' g and determined using Z-statistics at a significance level of p < 0.05. Heterogeneity was assessed using χ² and I² statistics. The individual and overall quality of evidence was assessed. Sensitivity and subgroup analyses were conducted. Narrative synthesis of outcomes was performed when meta-analysis could not be conducted on the data.

RESULTS

A total of 13,429 records were identified, and 10 randomised controlled trials in 11 articles amongst 1123 participants were included in the meta-analysis. Meta-analysis revealed that the electronic adherence monitoring device group was 1.50 times more likely to adhere to inhalers compared with the control group with medium-to-large effect size (g = 0.64). A series of subgroup analyses showed that no significant subgroup differences for inhaler adherence were found amongst different populations, comparator, setting, duration of the monitoring period, reminder, and feedback functions of the electronic adherence monitoring devices. Children found the devices as user friendly with high accessibility scores. However, no significant differences were observed between the intervention and control groups for asthma exacerbations, lung function and asthma control.

CONCLUSIONS

The findings from this study suggested that electronic adherence monitoring devices could improve inhaler adherence. Future devices should contain actuation and inhalation functions that can help to confirm actual inhalation amongst children with asthma. The overall evidence of outcomes ranged from very low to high. Furthermore, future large-scale trials were recommended before clinical implementations.

Improving adherence in chronic airways disease: are we doing it wrongly?

Non-adherence to medicines is a significant clinical and financial burden, but successful strategies to improve it, and thus bring about significant improvements in clinical outcome, remain elusive. Many barriers exist, including a lack of awareness amongst some healthcare professionals as to the extent and impact of non-adherence and a dearth of skills to address it successfully. Patients may not appreciate that they are non-adherent, feel they cannot disclose it or underestimate its impact on their health in the short and longer term. In describing the evidence-based frameworks that identify the causal factors behind medicines taking (or not taking) behaviours, we can start to personalise interventions to enable individuals to make informed decisions about their treatments and thus overcome real and perceived barriers to adherence.

Medicines non-adherence is common and associated with significant morbidity and mortality. @GrainnedAn and colleagues outline causal factors behind this behaviour and the appropriate individualised interventions available to support optimal medicines use.https://bit.ly/3ejJNTV

Issues Affecting Medication-Taking Behavior of People with Type 2 Diabetes in Indonesia: A Qualitative Study

PURPOSE

It has been widely acknowledged that non-adherence to medication among people with type 2 diabetes is a significant problem worldwide. Studies have suggested that non-adherence to medication may be caused by the complexity of issues surrounding medication use which further created burdens related to medication. However, studies on this topic in the Indonesian context were still limited. This study aimed to understand the experiences of people with type 2 diabetes in medication-taking and explore any practical issues that potentially affect their behavior when taking medication.

METHODS

Qualitative phenomenological study with semi-structured interviews was applied. The participants were purposefully recruited and selected from some primary healthcare facilities in Yogyakarta Province. The eligibility criteria included: diagnosed with type 2 diabetes by healthcare professionals for at least six months and were able to comprehend information. Information about the study was explained, and written informed consent was collected. The interviews were recorded, transcribed verbatim, and analyzed with a deductive qualitative content analysis method.

RESULTS

Fifty-one people with type 2 diabetes were involved in this study. Most of the participants were between 40 and 59 years old, and many of them were female and housewives. The thematic analysis found some practical issues that affected people's behavior in taking type 2 diabetes medication. These included individual's mealtime, characteristics of the medications, accessibility of healthcare services, experiences of side effects and social activities.

CONCLUSION

The practical issues identified in this study can be resolved by improving the role of healthcare providers in managing people with diabetes. Future research needs to be conducted to evaluate the effectiveness of interventions developed based on understanding of the practical factors identified.

Preventing a Post-Pandemic Double Burden of Disease in the COVID-19 Pandemic

As the world focuses on containing the spread of the coronavirus disease 2019 (COVID-19) and limiting the effects of the pandemic on the global population, care must be taken not to lose sight of existing individual health issues. There is a real risk of creating a 'post-pandemic double burden of disease'- where the pressures of having to manage acute COVID-19-related impacts on the health system are added to the existing burden of chronic non-communicable diseases or long-term conditions in developed countries. This could create a post-pandemic health crisis by devoting less attention to existing health conditions. A growing evidence base from other epidemics and health emergencies highlight the potential negative impact of short-term health crises on long-term public health. The significant disruptions to the usual healthcare systems and society can lead to increased morbidity and mortality in the long-term if not managed appropriately. This viewpoint provides an overview of the evidence to support the management of long-term conditions during, and after, health emergencies, to limit the impact of COVID-19 on public health in the short- and long-term.

Patients' and Clinicians' Visions of a Future Internet-of-Things System to Support Asthma Self-Management: Mixed Methods Study

BACKGROUND

Supported self-management for asthma reduces acute attacks and improves control. The internet of things could connect patients to health care providers, community services, and their living environments to provide overarching support for self-management.

OBJECTIVE

We aimed to identify patients' and clinicians' preferences for a future internet-of-things system and explore their visions of its potential to support holistic self-management.

METHODS

In an exploratory sequential mixed methods study, we recruited patients from volunteer databases and charities' social media. We purposively sampled participants to interview them about their vision of the design and utility of the internet of things as a future strategy for supporting self-management. Respondents who were not invited to participate in the interviews were invited to complete a web-based questionnaire to prioritize the features suggested by the interviewees. Clinicians were recruited from professional networks. Interviews were transcribed and analyzed thematically using PRISMS self-management taxonomy.

RESULTS

We interviewed 12 patients and 12 clinicians in the United Kingdom, and 140 patients completed the web-based questionnaires. Patients expressed mostly wanting a system to log their asthma control status automatically; provide real-time advice to help them learn about their asthma, identify and avoid triggers, and adjust their treatment. Peak flow (33/140, 23.6%), environmental (pollen, humidity, air temperature) (33/140, 23.6%), and asthma symptoms (25/140, 17.9%) were the specific data types that patient most wanted. Information about asthma and text or email access to clinical advice provided a feeling of safety for patients. Clinicians wanted automated objective data about the patients' condition that they could access during consultations. The potential reduction in face-to-face consultations was appreciated by clinicians which they perceived could potentially save patients' travel time and health service resources. Lifestyle logs of fitness regimes or weight control were valued by some patients but were of less interest to clinicians.

CONCLUSIONS

An automated internet-of-things system that requires minimal input from the user and provides timely advice in line with an asthma action plan agreed by the patient with their clinician was preferred by most respondents. Links to asthma information and the ability to connect with clinicians by text or email were perceived by patients as features that would provide a sense of safety. Further studies are needed to evaluate the usability and effectiveness of internet-of-things systems in routine clinical practice.

"You have to change your whole life": A qualitative study of the dynamics of treatment adherence among adults with tuberculosis in the United Kingdom

Maintaining adherence to treatment for tuberculosis (TB) is essential if the disease is to be eliminated. As part of formative research to develop an intervention to improve adherence, we documented the lived experiences of adults receiving anti-TB treatment (ATT) in three UK cities and examined how personal, social, and structural circumstances interacted to impact on individuals’ adherence to treatment. Using a topic guide that explored social circumstances and experiences of TB care, we conducted in-depth interviews with 18 adults (six women) who were being or had been treated for TB (patients) and four adults (all women) who were caring for a friend, relative, or partner being treated for TB (caregivers). We analysed transcripts using an adapted framework method that classified factors affecting adherence as personal, social, structural, health systems, or treatment-related. Eleven of 18 patients were born outside the UK (in South, Central, and East Asia, and Eastern and Southern Africa); among the seven who were UK-born, four were Black, Asian, or Minority Ethnic and three were White British. TB and its treatment were often disruptive: in addition to debilitating symptoms and side effects of ATT, participants faced job insecurity, unstable housing, stigma, social isolation, worsening mental health, and damaged relationships. Those who had a strong support network, stable employment, a routine that could easily be adapted, a trusting relationship with their TB team, and clear understanding of the need for treatment reported finding it easier to adhere to ATT. Changes in circumstances sometimes had dramatic effects on an individual’s ability to take ATT; participants described how the impact of certain acute events (e.g., the onset of side effects or fatigue, episodes of stigmatisation, loss of income) were amplified by their timing or through their interaction with other elements of the individual’s life. We suggest that the dynamic and fluctuating nature of these factors necessitates comprehensive and regular review of needs and potential problems, conducted before and during ATT; this, coupled with supportive measures that consider (and seek to mitigate) the influence of social and structural factors, may help improve adherence.

Improved adherence with Medicines Use Review service in Slovenia: a randomized controlled trial

Background

Based on several existing patient-oriented activities, Medicines Use Review (MUR) service was standardized and officially adopted in Slovenia in 2015. Service aims to provide adherence support and ensure safe and effective medicines use. Therefore, the aim of the study was to evaluate the benefits of MUR in Slovenia, primarily the impact on medication adherence.

Methods

A randomised controlled trial was performed in community pharmacies to compare MUR with standard care. Patients were randomised into either the test (patients received MUR by a certified MUR provider at visit 1), or control group. The study primary outcome was self-reported adherence to multiple medications, assessed by electronic ©Morisky Widget MMAS-8 Software at the first visit (V1) and after 12 weeks (V2). A sub-analysis of intentional and unintentional non-adherence was performed. MUR impact was defined as the relative difference in ©MMAS-8 score after 12 weeks between the test and control group. A multiple linear regression model was used to predict MUR impact based on baseline adherence (low versus medium and high). Several secondary outcomes (e.g. evaluation of drug-related problems (DRPs)) were also assessed.

Results

Data from 153 (V1) and 140 (V2) patients were analysed. Baseline adherence was low, moderate and high in 17.6, 48.4 and 34.0% patients, respectively. In the low adherence subpopulation, test group patients showed a 1.20 point (95% CI = 0.16–2.25) increase in total ©MMAS-8 score (p = 0.025) compared to control group patients. A 0.84 point (95% CI = 0.05–1.63) increase was due to intentional non-adherence (p = 0.038), and a 0.36 point (95% CI = − 0.23-0.95) was due to unintentional non-adherence (p = 0.226). Additionally, statistically significant decrease in the proportion of patients with manifested DRPs (p < 0.001) and concerns regarding chronic medicines use (p = 0.029) were revealed.

Conclusion

MUR service in Slovenia improves low medication adherence and is effective in addressing DRPs and concerns regarding chronic medicines use.

Trial registration

ClinicalTrials.gov - NCT04417400; 4th June 2020; retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06223-8.

Development and validation of a self-report measure of practical barriers to medication adherence - the Medication Practical barriers to Adherence Questionnaire (MPRAQ)

AIM

This study reports the development and validation of a new self-report measure (MPRAQ) that assesses practical barriers to medication adherence.

METHODS

MPRAQ comprises fifteen statements describing practical barriers. Responses are scored on a 5-point Likert scale; higher scores indicate more practical barriers. Initial face validity was evaluated by cognitive testing with patients from a diabetes support group. Following refinement, internal reliability and construct validity were assessed in two samples: patients recruited via Amazon mTurk and the Nivel Dutch Healthcare Consumer Panel (COPA). Respondents completed the Beliefs about Medicines Questionnaire (BMQ - general and specific), and Medication Adherence Report Scale (MARS-5). The mTurk sample also completed the Perceived Sensitivity to Medicines questionnaire (PSM), and repeated MPRAQ two weeks later to assess test-retest reliability.

RESULTS

Face validity was evaluated in 15 patients (46% female; mean (SD) age 64(12) years). A total of 184 mTurk participants completed the questionnaire (in English) and 334 in COPA (in Dutch). Internal reliability was acceptable (mTurk α=0.89; COPA α=0.94). Construct validity was confirmed, with significant correlation between MPRAQ and BMQ-Specific Concerns (mTurk r=0.546, p<0.0001; COPA r=0.370, p<0.0001); BMQ-General Harm (mTurk r=0.504, p<0.0001; COPA r=0.219, p<0.0001); BMQ-General Overuse (mTurk, r=0.324, p<0.0001; COPA r=0.109, p=0.047), and PSM (mTurk only, r=0.463, p<0.0001), and a negative correlation with MARS-5 (mTurk r=-0.450, p<0.0001; COPA r=-0.260, p<0.0001). MPRAQ did not correlate with BMQ-Specific Necessity or BMQ-General Benefit. Correlation between MPRAQ baseline and 2-week follow-up scores confirmed test-retest reliability (r=0.745, p<0.0001; n=52).

CONCLUSION

MPRAQ is a reliable and valid self-report measure of practical adherence barriers.

A Qualitative Study of Factors Influencing Adherence among Pregnant Women Taking Part in a Trial of E-Cigarettes for Smoking Cessation

Use of e-cigarettes (vaping) has potential to help pregnant women stop smoking. This study explored factors influencing adherence among participants in the vaping arm of the first trial of vaping for smoking cessation in pregnancy. We conducted semi-structured telephone interviews (n = 28) with women at three-months postpartum. Interviews were analysed using thematic analysis, informed by the Theoretical-Domains Framework, Necessity-Concerns Framework and Perceptions and Practicalities Approach. Interviewees generally reported high levels of vaping. We found that: (1) intervention adherence was driven by four necessity beliefs-stopping smoking for the baby, and vaping for harm reduction, smoking cessation or as a last resort; (2) necessity beliefs outweighed vaping concerns, such as dependence and safety; (3) adherence was linked to four practicalities themes, acting as barriers and facilitators to vaping-device and e-liquid perceptions, resources and support, whether vaping became habitual, and social and environmental factors; and (4) intentional non-adherence was rare; unintentional non-adherence was due to device failures, forgetting to vape, and personal circumstances and stress. Pregnant smokers provided with e-cigarettes, and with generally high levels of vaping, had positive beliefs about the necessity of vaping for smoking cessation which outweighed concerns about vaping. Non-adherence was mainly due to unintentional factors.