Reliability of a medication adherence measure in an outpatient setting

Performance of Medication Tasks: Relationship Among Patient-Reported Outcomes, Performance-Based Assessments, and Objective Assessments

IMPORTANCE

Occupational therapy practitioners use standardized assessments to guide their clinical decision-making, but it is unclear how well performance on standardized assessments translates to performance at home.

OBJECTIVE

To understand the concurrent and predictive validity of patient-reported outcomes and performance-based assessments for monitoring performance at home within the context of medication management and adherence.

DESIGN

Exploratory study.

SETTING

Participants completed standardized assessments in a lab or at home, which were followed by home-based electronic monitoring of medication adherence.

PARTICIPANTS

Sixty community-dwelling adults with hypertension or stroke who independently took antihypertensive medications.

OUTCOMES AND MEASURES

Participants completed the Hill-Bone Medication Adherence Scale, the Hill-Bone Medication Adherence Reasons Scale, the Performance Assessment of Self-Care Skills Medication Management subtask, and the Executive Function Performance Test-Enhanced Medication Management subtest. Then, they used an electronic pill cap to monitor medication adherence at home for 1 month.

RESULTS

Patient-reported outcomes and performance-based assessments in the context of medication management and adherence demonstrated poor concurrent and predictive validity to medication adherence at home.

CONCLUSIONS AND RELEVANCE

There is a gap between what people think they will do, what they can do on a standardized assessment, and what they actually do at home. Future research is needed to strengthen concurrent and predictive validity to clinically meaningful outcomes. Plain-Language Summary: Occupational therapy practitioners should use caution when using standardized assessments to try to predict client performance at home. They should also continue to use a battery of assessments, clinical reasoning, and client preferences to guide their decision-making for monitoring performance at home within the context of medication management and adherence.

A Systematic Review of the Hill-Bone Compliance to Blood Pressure Therapy Scale

Background

Poor medication adherence hampers hypertension control and increases the risk of adverse health outcomes. Medication adherence can be measured with direct and indirect methods. The Hill-Bone Compliance to High Blood Pressure Therapy (HBCHBPT) Scale, one of the most popular adherence measures, indirectly assesses adherence to hypertension therapy in three behavioral domains: appointment keeping, diet and medication adherence.

Aim

To synthesize evidence on the use of the HBCHBPT Scale, including psychometric properties, utility in diverse patient populations, and directions for future clinical use and research.

Methods

We searched electronic databases, specifically CINAHL, PubMed, PsychInfo, Embase, and Web of Science. We included original studies that used the HBCHBPT Scale or its subscales to measure a health outcome, or methodological studies involving translations and validations of the scale. We extracted and synthesized data following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines.

Results

Fifty studies were included in this review, 44 on hypertension, two on diabetes, and others on other chronic conditions. The scale was successfully translated into numerous languages and used in descriptive and intervention studies. The scale demonstrated sound psychometric properties (Cronbach's α coefficient 0.75) and sensitivity to capture intervention effects when used to evaluate the effectiveness of high blood pressure adherence interventions. The medication-taking subscale of HBCHBPT performs best and is widely used in diverse contexts to assess medication adherence for chronic conditions.

Conclusion

The HBCHBPT Scale has high versatility globally and has been used in various settings by various healthcare worker cadres and researchers. The scale has several strengths, including high adherence phenotyping capabilities, contributing to the paradigm shift toward personalized health care.

Measurement Tools and Utility of Hair Analysis for Screening Adherence to Antihypertensive Medication

Poor adherence to the prescribed antihypertensive therapy is an understated public health problem and is one of the main causes of the high prevalence of uncontrolled hypertension in sub-Saharan Africa. Medication adherence is vital for the effectiveness of antihypertensive treatment and is key to ameliorating the clinical outcomes in hypertensive patients. However, it has often been ignored because the current methods used to assess medication adherence are not reliable, limiting their utilization in clinical practice. Therefore, the identification of the most accurate and clinically feasible method for measuring medication adherence is critical for tailoring effective strategies to improve medication adherence and consequently achieve blood pressure goals. This review not only explores various available methods for estimating medication adherence but also proposes therapeutic drug monitoring in hair for the measurement of medication adherence to the antihypertensive medication period.

Application of family-involved smart medication management system in rural-dwelling middle-aged and older adult participants with chronic diseases: Management of chronic diseases in rural areas

Management of patients with chronic diseases in rural areas and the use of medications need to be urgently addressed. Therefore, this study aimed to evaluate the efficacy of a family-involved smart medication management system for rural patients with chronic diseases. Between June and August 2021, 82 patients with chronic diseases were selected using convenience sampling from 2 county towns in Hebei Province, China. They were randomly divided into control (41 participants) and experimental (41 participants) groups. The control group was managed using a routine medication management model for chronic diseases. The experimental group was managed using a family-involved smart medication management system, in addition to the control group interventions. The groups were graded using the 8-item Morisky Medication Adherence Scale (MMAS-8), the Self-efficacy for Appropriate Medication Use Scale (SEAMS), the Medication Knowledge Assessment Questionnaire, and the Family Support Scale before the intervention and at 8 and 24 weeks after the intervention. Pre-intervention group differences were not statistically significant. At 8 weeks after the intervention, the control group showed no statistically significant differences in the MMAS-8, SEAMS, and Medication Knowledge Assessment scores pre-and post-intervention. These scores were higher in the experimental group than in the control group, with the post-intervention scores being higher than the pre-intervention scores. The MMAS-8, SEAMS, and Medication Knowledge Assessment scores for the experimental group were higher at 24 weeks than at 8 weeks; these scores were higher in the experimental group than in the control group. The experimental group also had higher family support scores than the control group; these scores were higher pre-intervention than post-intervention. A family-involved smart medication management system can effectively improve medication adherence, self-efficacy for appropriate medication use, medication knowledge assessment scores, and family support for rural middle-aged and older adult patients with chronic diseases.

Measurement Properties of Patient-Reported Outcome Measures for Medication Adherence in Cardiovascular Disease: A COSMIN Systematic Review

BACKGROUND AND OBJECTIVE

Several medication adherence patient-reported outcome measures (MA-PROMs) are available for use in patients with cardiovascular disease (CVD); however, little evidence is available on the most suitable MA-PROM to measure medication adherence in patients with CVD. The aim of this systematic review is to synthesise the measurement properties of MA-PROMs for patients with CVD and identify the most suitable MA-PROM for use in clinical practice or future research in patients with CVD.

METHODS

An electronic search of nine databases (PubMed, MEDLINE, CINAHL, ProQuest Health and Medicine, Cochrane Library, PsychInfo, Scopus, Embase, and Web of Science) was conducted to identify studies that have reported on at least one of the measurement properties of MA-PROMs in patients with CVD. The methodological quality of the studies included in the systematic review was evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

RESULTS

A total of 40 MA-PROMs were identified in the 84 included studies. This review found there is a lack of moderate-to-high quality evidence of sufficient content validity for all MA-PROMs for patients with CVDs. Only eight MA-PROMs were classified in COSMIN recommendation category A. They exhibited sufficient content validity with very low-quality evidence, and moderate-to-high quality evidence for sufficient internal consistency. The 28 MA-PROMs that meet the requirements for COSMIN recommendation category 'B' require further validation studies. Four MA-PROMs including Hill-Bone Compliance Medication Scale (HBMS), the five-item Medication Adherence Report Scale (MARS-5), Maastricht Utrecht Adherence in Hypertension (MUAH), and MUAH-16 have insufficient results with high quality evidence for at least one measurement property and consequently are not recommended for use in patients with CVD. Two MA-PROMs (Adherence to Refills and Medications Scale [ARMS] and ARMS-7) are comprehensive and have moderate to high quality evidence for four sufficient measurement properties.

CONCLUSION

From the eight MA-PROMs in COSMIN recommendation category A, ARMS and ARMS-7 were selected as the most suitable MA-PROMs for use in patients with CVD. They are the most comprehensive with be best quality evidence to support their use in clinical practice and research.

Measurement Properties of Existing Patient-Reported Outcome Measures on Medication Adherence: Systematic Review

Background

Medication adherence is essential for improving the health outcomes of patients. Various patient-reported outcome measures (PROMs) have been developed to measure medication adherence in patients. However, no study has summarized the psychometric properties of these PROMs to guide selection for use in clinical practice or research.

Objective

This study aims to evaluate the quality of the PROMs used to measure medication adherence.

Methods

This study was guided by the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Relevant articles were retrieved from the EMBASE, PubMed, Cochrane Library, Web of Science, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. The PROMs were then evaluated based on the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines.

Results

A total of 121 unique medication adherence PROMs from 214 studies were identified. Hypotheses testing for construct validity and internal consistency were the most frequently assessed measurement properties. PROMs with at least a moderate level of evidence for ≥5 measurement properties include the Adherence Starts with Knowledge 20, Compliance Questionnaire-Rheumatology, General Medication Adherence Scale, Hill-Bone Scale, Immunosuppressant Therapy Barrier Scale, Medication Adherence Reasons Scale (MAR-Scale) revised, 5-item Medication Adherence Rating Scale (MARS-5), 9-item MARS (MARS-9), 4-item Morisky Medication Adherence Scale (MMAS-4), 8-item MMAS (MMAS-8), Self-efficacy for Appropriate Medication Adherence Scale, Satisfaction with Iron Chelation Therapy, Test of Adherence to Inhalers, and questionnaire by Voils. The MAR-Scale revised, MMAS-4, and MMAS-8 have been administered electronically.

Conclusions

This study identified 121 PROMs for medication adherence and provided synthesized evidence for the measurement properties of these PROMs. The findings from this study may assist clinicians and researchers in selecting suitable PROMs to assess medication adherence.

Development of an Item Bank to Measure Medication Adherence: Systematic Review

Background

Medication adherence is important in managing the progression of chronic diseases. A promising approach to reduce cognitive burden when measuring medication adherence lies in the use of computer‐adaptive tests (CATs) or in the development of shorter patient-reported outcome measures (PROMs). However, the lack of an item bank currently hampers this progress.

Objective

We aim to develop an item bank to measure general medication adherence.

Methods

Using the preferred reporting items for systematic review and meta-analysis (PRISMA), articles published before October 2019 were retrieved from PubMed, Embase, CINAHL, the Cochrane Library, and Web of Science. Items from existing PROMs were classified and selected (“binned” and “winnowed”) according to standards published by the Patient-Reported Outcomes Measurement Information System (PROMIS) Cooperative Group.

Results

A total of 126 unique PROMs were identified from 213 studies in 48 countries. Items from the literature review (47 PROMs with 579 items for which permission has been obtained) underwent binning and winnowing. This resulted in 421 candidate items (77 extent of adherence and 344 reasons for adherence).

Conclusions

We developed an item bank for measuring general medication adherence using items from validated PROMs. This will allow researchers to create new PROMs from selected items and provide the foundation to develop CATs.

Medication adherence and self-care behaviours among patients with type 2 diabetes mellitus in Ghana

BACKGROUND

Diabetes often coexists with other medical conditions and is a contributing cause of death in 88% of people who have it. The study aimed at evaluating medication adherence, self-care behaviours and diabetes knowledge among patients with type 2 diabetes mellitus in Ghana.

METHODS

A total of 330 participants were recruited into the study from three public hospitals in the Tamale metropolis. A validated medication adherence questionnaire and the Summary of Diabetes Self-care Activities tool were used to assess medication adherence and self-care activities respectively. Logistic and linear regressions were used to determine factors positively associated with non-adherence to medication and self-care behaviours respectively.

RESULTS

Of the 330 participants whose data were analysed, the mean (SD) age was 57.5 (11.8) years. The majority (84.5%) were adherent to anti-diabetes medication. Participant's age, educational level, and practice of self-care behaviours influenced adherence to anti-diabetes medication. Participants aged 70 years and above were 79% less likely to be non-adherent to medication as compared to those below 50 years [OR = 0.21 (95%CI: 0.06-0.74), p = 0.016]. Participants with senior high school education were 3.7 times more likely to be non-adherent to medication than those with tertiary education [OR = 3.68 (95%CI: 1.01-13.44), p = 0.049]. Participants with tertiary education had an increase in the level of practice of self-management by 1.14 (p = 0.041). A unit increase in knowledge score also increased the level of practice of self-management by 3.02 (p<0.001).

CONCLUSION

The majority of participants were adherent to anti-diabetes medication. Non-adherence to medication was associated with younger age and low level of education. Interventions to improve adherence should target younger and newly diagnosed patients through aggressive counselling to address healthy self-management behaviours.

A cross-sectional study on the rate of non-adherence to anti-seizure medications and factors associated with non-adherence among patients with epilepsy

Background

Non-adherence to anti-seizure medication (ASM) therapy is an important contributing factor to the higher mortality rate and treatment failure of epilepsy. This study aimed to determine the rate and factors associated with non-adherence to ASM therapy through the WHO five dimensions of medication adherence framework.

Methods

We conducted a cross-sectional study at an outpatient Neurology Clinic of a tertiary government hospital in Malaysia. Between March and July 2019, we identified 217 patients with a confirmed diagnosis of epilepsy, receiving oral ASM therapy and able to administer their medications. We performed a semi-structured interview to gather information on sociodemographic background, clinical and medication history, and perceptions on healthcare services. Adherence to ASM therapy was evaluated using the Medication Compliance Questionnaire (MCQ). Patient’s illness perception was assessed by the Brief Illness Perception Questionnaire (B-IPQ).

Results

208 patients participated in this study. The median age of the study participants was 35 years (IQR 26–44). 58.2% were females and majority, 55.8%, were from the Malay ethnic group. Based on the MCQ scoring, 89 patients (42.8%) were non-adherent. Multiple logistic regression demonstrated that being employed or students (adjusted odds ratio [aOR] 2.26, 95%CI: 1.19–4.29 p = 0.012) and having an average or below average perceived access to pharmacy services (aOR 2.94, 95%CI: 1.38–6.24, p = 0.005) were significant contributors to non-adherence.

Conclusion

Being employed or students and having an average or below average perceived access to pharmacy services were associated with ASM non-adherence Efforts to improve ASM adherence should adopt a comprehensive approach considering the success of adherence is contingent on the interrelationship of multiple dimensions.

Questionnaires on adherence to antihypertensive treatment: a systematic review of published questionnaires and their psychometric properties

Background Non-adherence to antihypertensive treatment is currently considered one of the most significant risk factors in failure to achieve controlled blood pressure values. It is therefore extremely important to measure patient adherence to antihypertensive treatment. One way to measure adherence is through questionnaires. Numerous questionnaires for measuring adherence to antihypertensive treatment have been validated, but it not easy to choose one of them as being more appropriate than all of the others. Aim of the review The aim of this study was to identify and assess questionnaires designed to measure non-adherence to antihypertensive treatment, and to discuss their psychometric properties. Method A systematic review of the literature contained in PubMed and Scopus databases was undertaken to identify validated questionnaires on adherence to antihypertensive treatment up to October 2017. PRISMA guidelines were followed to conduct and report this review. Selection of articles and data extraction were performed by two independent researchers. When there was lack of agreement, a third researcher mediated in the discussion between the first two authors so that consensus could be reached. Results 39 articles were obtained containing 17 different questionnaires for measuring adherence to antihypertensive treatment. These questionnaires were validated in 15 countries. The number of items in the questionnaires ranged from three in QAM-Q to 33 in TAQPH. Hill-Bone compliance to high blood pressure therapy scale, Morisky-Green-Levine test and an 8-item Self-Reported Medication Adherence Measurement were the most widely validated questionnaires. Validity was analyzed more than reliability. Many of the questionnaires do not provide information on content validity. Construct validity and concurrent validity are analyzed in almost all of the questionnaires, and give highly variable results. By contrast, known-groups validity was not analyzed to any great degree. As regards reliability, almost all of the questionnaires provided Cronbach's alpha information with reasonably acceptable results, but temporal stability was not analyzed to any great degree. Conclusion None of the questionnaires included in the review demonstrates fulfilling all of the validity tests (content validity, construct validity and criterion-related validity) and reliability tests (homogeneity and temporal stability) in an acceptable manner. Therefore, none of them can be considered a Gold Standard.

The Translation, Reliability and Validity of the Chinese Version of the Hill-Bone Compliance to High Blood Pressure Therapy Scale in Adults with Hypertension

OBJECTIVE

To assess the reliability and validity of the Chinese version of the Hill-Bone compliance to high blood pressure therapy scale (HBTS) for use in adults with hypertension in China.

METHODS

To develop a Chinese version of the study scale, it was translated into Chinese then back-translated into English. The final version was used in a survey conducted between Jan and June 2019 in a hospital in Xi'an, China. Reliability was assessed by using the Cronbach's alpha as a measure of analyzing the internal consistency. Exploratory factor analysis (EFA) was performed to assess the validity of the Chinese scale.

RESULTS

The EFA revealed a four-component structure representing two of medication taking; appointment keeping and reduced sodium intake. Percentages of explained variance were 37.55%, 52.77%, 65.24% and 73.97%, respectively. All questions have factor loadings >0.4. The Cronbach's alpha score for the entire questionnaire was 0.857.

CONCLUSION

The Chinese Hill-Bone scale (HBTS-C) is a valid and reliable instrument for measuring adherence among Chinese with hypertension. Use of this screening tool for the assessment of adherence to hypertension treatment is recommended.

Adherence to antidiabetic medication and factors associated with non-adherence among patients with type-2 diabetes mellitus in two regional hospitals in Cameroon

BACKGROUND

Diabetes mellitus is a growing cause of disease burden globally. Its management is multifaceted, and adherence to pharmacotherapy is known to play a significant role in glycaemic control. Data on medication adherence among affected patients is unknown in Cameroon. In this study, the level of adherence and factors influencing non-adherence to antidiabetic medication among patients with type-2 diabetes was assessed.

METHODS

A hospital-based cross-sectional study among adult patients receiving care in the diabetic clinics of the Limbe and Bamenda Regional Hospitals in Cameroon was conducted. Medication adherence was assessed using the Medication Compliance Questionnaire (MCQ). Factors associated with non-adherence to medication were determined using basic and adjusted multivariable logistic regression models.

RESULTS

A total of 195 patients with type 2 diabetes were recruited. The prevalence of non-adherence to medication was 54.4% [95% confidence interval (CI): 47.1-61.5%]. In multivariable analysis, age > 60 years (aO.R. = 0.48, 95% CI: 0.25-0.94), alcohol consumption (aO.R. = 2.13, 95% CI: 1.10-4.14) and insulin alone therapy (aO.R. = 2.85, 95% CI: 1.01-8.08) were associated with non-adherence. Patients attributed their non-adherence to forgetfulness (55.6%), lack of finances (38.2%) and disappearance of symptoms (14.2%).

CONCLUSIONS

Adherence to anti-diabetic medication is poor in this study with more than half of participants being non-adherent. Urgent interventions are required to tackle this problem in combined efforts to stem this looming diabetes epidemic.

Nutrition Counseling for Hypertension Within a Grocery Store: An Example of the Patient-Centered Medical Neighborhood Model

OBJECTIVE

To evaluate the effectiveness of nutrition counseling for patients with hypertension, provided in a grocery store setting.

DESIGN

Single-arm pretest-posttest design implementing a 12-week dietary intervention.

SETTING

Grocery store.

PARTICIPANTS

Thirty adults with hypertension recruited from a primary care practice.

INTERVENTION

Registered dietitian nutritionists provided counseling based on the Dietary Approaches to Stop Hypertension diet.

MAIN OUTCOME MEASURES

Dietary intake patterns and Healthy Eating Index-2010 (HEI-2010) scores measured via food-frequency questionnaire. Change in systolic blood pressure (SBP) was a secondary outcome.

ANALYSIS

Paired t tests were used to test for differences between HEI-2010 scores, intake of key food pattern components, and SBP at baseline compared with follow-up. Statistical significance was established at P ≤ .05.

RESULTS

Eight HEI-2010 component scores increased significantly from baseline to follow-up (a change toward a more desirable eating pattern): total fruit, whole fruit, greens and beans, whole grains, fatty acids, refined grains, and empty calories. Sodium (P < .001), saturated fat (P < .001), discretionary solid fat (P < .001), added sugars (P = .01), and total fat (P < .001) all decreased significantly. The change in SBP was not significant.

CONCLUSIONS AND IMPLICATIONS

Grocery store-based counseling for patients with hypertension may be an effective strategy to provide lifestyle counseling that is not typically available within primary care.

Assessment of adherence to medication in patients after myocardial infarction treated with percutaneous coronary intervention. Is there a place for newself-reported questionnaires?

INTRODUCTION

Non-adherence to medication regimen after myocardial infarction (MI) leads to increased morbidity and mortality and generates additional cost to the healthcare system.

OBJECTIVES

The aim of this systematic review was to critically discuss assessment methods of adherence to medication in patients after myocardial infarction treated with percutaneous coronary intervention and the possible application of a new self-reported questionnaire.

METHODS

A systematic investigation of all published literature was conducted to minimize the risk of bias. A database search (PubMed, CENTRAL and Google Scholar databases) from January 1998 through December 2017.

RESULTS

Adequate assessment of patient adherence to treatment is necessary to understand the potential for adverse outcomes. Methods developed for adherence evaluation are classified as subjective and objective or as direct and indirect. Direct, objective measures reflect pharmacokinetics and include measurement of the drug or its metabolite concentration, evaluation of the presence of biological markers given with the drug and direct observation of patients' medication-taking behavior. Several indirect, objective methods are based on evaluation of the availability of prescribed medications assuming that medication is taken exactly as prescribed. Assessment of the effectiveness of treatment, both at the pharmacodynamic and clinical level, indirectly but objectively reflects adherence to treatment. Subjective methods, including patient-kept diaries, patient interviews and self-reported questionnaires, due to their simplicity, real-time feedback and low cost, are often used for adherence evaluation in clinical practice.

CONCLUSIONS

In spite of the availability, convenience and variety of methods, measuring adherence still remains a real challenge. Using a well designed questionnaire provides an opportunity to identify patients at increased risk of non-adherence and the obstacles impeding implementation of the treatment plan, allowing implementation of tailored interventions in order to improve patient medication-taking behavior.

Factors associated with uncontrolled blood pressure among Ghanaians: Evidence from a multicenter hospital-based study

BACKGROUND

The burden of uncontrolled hypertension in Low-and-Middle Income Countries (LMICs) is high, with an increased risk of cardiovascular diseases and chronic renal failure in these settings.

OBJECTIVE

To assess the factors associated with uncontrolled blood pressure control in a cross-section of Ghanaian hypertensive subjects involved in an on-going multicenter epidemiological study aimed at improving access to hypertension treatment.

METHODS

A cross-sectional study involving 2,870 participants with hypertension with or without diabetes who were enrolled at 5 hospitals in Ghana (2 tertiary, 2 district and 1 rural hospital). Data on demographics, medical history, lifestyle factors, anti-hypertensive medications and treatment adherence were collected. The 14-item version of the Hill-Bone compliance to high blood pressure therapy scale was used to assess adherence to treatment in 3 domains namely adherence to medications, salt intake and clinic appointments. Questionnaires on knowledge, attitudes and practices on hypertension, sources of antihypertensive medications and challenges with accessing these medications were also administered. Blood pressure, weight and height were measured for each subject at enrollment. Factors associated with uncontrolled blood pressure (>140/90mmHg) were assessed using a multivariate logistic regression model.

RESULTS

The mean ± SD age of study participants was 58.9 ± 16.6 years, with a female preponderance (76.8%). Among study participants, 1,213 (42.3%) study participants had blood pressure measurements under control. Factors that remained significantly associated with uncontrolled blood pressure with adjusted OR (95% CI) included receiving therapy at a tertiary level of care: 2.47 (1.57-3.87), longer duration of hypertension diagnosis: 1.01 (1.00-1.03), poor adherence to therapy: 1.21 (1.09-1.35) for each 5 points higher score on the Hill-Bone scale, reported difficulties in obtaining antihypertensive medications: 1.24 (1.02-1.49) and number of antihypertensive medications prescribed: 1.32 (1.21-1.44).

CONCLUSION

We have found high rates of uncontrolled blood pressure among Ghanaian patients with hypertension accessing healthcare in public institutions. The system-level and individual-level factors associated with poor blood pressure control should be addressed to improve hypertension management among Ghanaians.

Drug adherence for antihypertensive medications and its determinants among adult hypertensive patients attending in chronic clinics of referral hospitals in Northwest Ethiopia

BACKGROUND

Adherence to prescribed medication is an imperative issue which can be directly linked with the management of chronic diseases like hypertension; failure to adhere can affect the effectiveness of medication as well as the efficiency of the health care system. There is scarcity of information regarding the level of drug adherence for antihypertensive medications and its determinants in Ethiopia, particularly in the study area. Therefore, the aim of this study was to assess adherence level and its determinants for antihypertensive medications among adult hypertensive patients attending the chronic illness clinics of the referral hospitals in northwest Ethiopia.

METHODS

Institution based cross sectional study was conducted from March to April, 2016. The systematic random sampling technique was used to select 409 study participants from three referral hospitals. The questionnaire was prepared using the World Health Organization (WHO) conceptual model and by reviewing international literature. The data were collected using an interviewer administered questionnaire. The data were entered in to Epi - Info version 7 and then transferred to the statistical package for social science (SPSS) version 20 for data cleaning and analysis. Bivariate analysis was first done to see the association between each independent variables and dependent variable. Variables with a P-value of less than 0.2 in the bivariate analysis were entered in to the multivariate logistic regression model for final analysis. Multivariate analysis was done using Backward logistic regression method. P-value less than 0.05 was considered to determine the statistical significance of the association and odds ratio with a 95% confidence interval was used to determine the presence, strength, and direction of association between covariates (explanatory variables) and the outcome variable. The Morisky medication adherence scale was used to assess the adherence status using > = 6 as adherent or < 6 as non adherent score.

RESULTS

Four hundred and nine (409) study participants were interviewed with a response rate of 100%. The mean age of the respondents was 54.5 years with (Standard Deviation (SD) ± 13.58). The overall rate of good adherence was 67.2% (95% CI = 62.8, 71.6). Participants who had a favourable attitude towards antihypertensive medications (Adjusted odds ratio (AOR) = 9.88, 95% confidence interval (CI): 5.34, 18.27), having good patient- provider relationship (AOR = 4.25, 95% CI: 2.32, 7.86), having one (AOR = 4.36, 95% CI: 1.34, 14.12) or no (AOR = 3.38, 95% CI:1.01,11.31) co-morbidities, a long duration of treatment (AOR = 1.89, 95%CI: 1.07, 3.35), and a low medical cost (AOR = 2.06, 95% CI: 1.13, 3.76) had associations with good drug adherence for antihypertensive medication/s.

CONCLUSIONS

The prevalence of good drug adherence for anti-hypertensive medications in this study was high. Prevention of co- morbidities, making medical services accessible, and maintaining good client-provider interaction are of paramount importance for good drug adherence.

Determinants of adherence to antiretroviral therapy among HIV-positive adults in sub-Saharan Africa: a systematic review

OBJECTIVE

The rapid scale up of antiretroviral treatment (ART) in sub-Saharan Africa (SSA) has resulted in an increased focus on patient adherence. Non-adherence can lead to drug-resistant HIV caused by failure to achieve maximal viral suppression. Optimal treatment requires the identification of patients at high risk of suboptimal adherence and targeted interventions. The aim of this review was to identify and summarise determinants of adherence to ART among HIV-positive adults.

DESIGN

Systematic review of adherence to ART in SSA from January 2002 to October 2014.

METHODS

A systematic search was performed in 6 databases (PubMed, Cochrane Library, EMBASE, Web of Science, Popline, Global Health Library) for qualitative and quantitative articles. Risk of bias was assessed. A meta-analysis was conducted for pooled estimates of effect size on adherence determinants.

RESULTS

Of the 4052 articles screened, 146 were included for final analysis, reporting on determinants of 161 922 HIV patients with an average adherence score of 72.9%. Main determinants of non-adherence were use of alcohol, male gender, use of traditional/herbal medicine, dissatisfaction with healthcare facility and healthcare workers, depression, discrimination and stigmatisation, and poor social support. Promoters of adherence included counselling and education interventions, memory aids, and active disclosure among people living with HIV. Determinants of health status had conflicting influence on adherence.

CONCLUSIONS

The sociodemographic, psychosocial, health status, treatment-related and intervention-related determinants are interlinked and contribute to optimal adherence. Clinics providing ART in SSA should therefore design targeted interventions addressing these determinants to optimise health outcomes.

Evaluation of the Measurement Properties of Self-reported Medication Adherence Instruments Among People at Risk for Metabolic Syndrome: A Systematic Review

PURPOSE

The purpose of this study was to present a systematic review of available published studies that evaluated the measurement properties of self-reported instruments assessing global medication adherence in adults at risk for metabolic syndrome.

METHODS

The authors searched PubMed, EMBASE, PsycINFO, and CINAHL in January 2015 for appropriate studies. The methodological quality (based on reliability, validity, responsiveness, and interpretability) of selected studies was assessed with the COSMIN checklist (Consensus-Based Standards for the Selection of Health Measurement Instruments).

RESULTS

Of the 44 studies reviewed, 32 used classical test theory, and 14 used self-reported medication adherence instruments. More than half the studies included patients with hypertension, followed by diabetes, dyslipidemia, and increased body mass index. Among the measurement properties, internal consistency, hypothesis testing, and structural validity were frequently assessed items, whereas only 1 study evaluated responsiveness, and none evaluated measurement error. The MMAS-8 (Morisky Medication Adherence Scale-8 items) and the Hill-Bone scale were the most frequently used instruments. They were found to be well validated, with strong evidence for internal consistency and strong positive evidence for reliability, structural validity, hypothesis testing, and criterion validity.

CONCLUSIONS

The MMAS-8 and Hill-Bone scale seem to be well-validated instruments for assessing medication adherence in adults at risk for metabolic syndrome. These findings may assist clinicians with selecting the appropriate instruments for assessing medication adherence in this population. However, further studies might be needed to define concepts to better understand the dimensions of each medication adherence instrument.

Psychometric evaluation of the Polish adaptation of the Hill-Bone Compliance to High Blood Pressure Therapy Scale

Background

Development of simple instruments for the determination of the level of adherence in patients with high blood pressure is the subject of ongoing research. One such instrument, gaining growing popularity worldwide, is the Hill-Bone Compliance to High Blood Pressure Therapy.

The aim of this study was to adapt and to test the reliability of the Polish version of Hill-Bone Compliance to High Blood Pressure Therapy Scale.

Methods

A standard guideline was used for the translation and cultural adaptation of the English version of the Hill-Bone Compliance to High Blood Pressure Therapy Scale into Polish. The study included 117 Polish patients with hypertension aged between 27 and 90 years, among them 53 men and 64 women. Cronbach’s alpha was used for analysing the internal consistency of the scale.

Results

The mean score in the reduced sodium intake subscale was M = 5.7 points (standard deviation SD = 1.6 points). The mean score in the appointment-keeping subscale was M = 3.4 points (standard deviation SD = 1.4 points). The mean score in the medication-taking subscale was M = 11.6 points (standard deviation SD = 3.3 points). In the principal component analysis, the three-factor system (1 – medication-taking, 2 – appointment-keeping, 3 – reduced sodium intake) accounted for 53 % of total variance. All questions had factor loadings > 0.4. The medication-taking subscale: most questions (6 out of 9) had the highest loadings with Factor 1. The appointment-keeping subscale: all questions (2 out of 2) had the highest loadings with Factor 2. The reduced sodium intake subscale: most questions (2 out of 3) had the highest loadings with Factor 3. Goodness of fit was tested at chi² = 248.87; p < 0.001. The Cronbach’s alpha score for the entire questionnaire was 0.851.

Conclusion

The Hill-Bone Compliance to High Blood Pressure Therapy Scale proved to be suitable for use in the Polish population. Use of this screening tool for the assessment of adherence to BP treatment is recommended.

The influence of illness acceptance on the adherence to pharmacological and non-pharmacological therapy in patients with hypertension

BACKGROUND

The available publications show that 50% of patients with hypertension discontinue their medications within the first 12 months after the beginning of treatment.

AIM

The aim of the study was to analyse the relationship between the acceptance of illness and the adherence to pharmacological and non-pharmacological therapy in patients with hypertension.

METHODS

The study included 102 patients with hypertension examined with validated instruments: Acceptance of Illness Scale (AIS), Health Behavior Inventory (HBI) and Morisky Medication Adherence Scale (MMAS-8).

RESULTS

High (>30 points) and moderate (19-29 points) levels of AIS were presented respectively by 59 and 43 patients. In a univariate analysis, the level of AIS had a statistically significant, independent, positive influence on all domains of the HBI questionnaire: HBI (Spearman's coefficient of rank correlation (r_S) =+0.3997), healthy eating habits (r_S=+ 0.376), preventive behaviours (r_S=+0.242), positive mental attitude (r_S=+0.504), health practices (r_S=+0.264). In univariate analysis the level of MMAS-8 was influenced by female gender (r_S=+0.325; p=0.001), higher education level (r_S=+0.241; p=0.015), employment (r_S=+0.217; p=0.029) and short duration of illness (r_S=+0.229; p=0.022). Multiple regression analysis showed that female gender was an independent predictor of pharmacological adherence (β=+0.325; p=0.001). Illness acceptance was an independent predictor in two domains of the HBI: positive mental attitude HBI domain (β=+0.468; p<0.001) and healthy eating habits (β=+0.321; p=0.001).

CONCLUSIONS

(1) Correlation analysis shows that illness acceptance is an important factor contributing to a higher level of adherence to non-pharmacological therapy of hypertension (total index of health behaviours: healthy eating habits, preventive behaviours, positive mental attitude, health practice) but has no influence on adherence to pharmacological treatment. (2) Female gender, higher levels of education, and the short duration of the disease significantly improve patients' adherence to the prescribed pharmacological and non-pharmacological therapy of hypertension.

Medication Adherence Measures: An Overview

WHO reported that adherence among patients with chronic diseases averages only 50% in developed countries. This is recognized as a significant public health issue, since medication nonadherence leads to poor health outcomes and increased healthcare costs. Improving medication adherence is, therefore, crucial and revealed on many studies, suggesting interventions can improve medication adherence. One significant aspect of the strategies to improve medication adherence is to understand its magnitude. However, there is a lack of general guidance for researchers and healthcare professionals to choose the appropriate tools that can explore the extent of medication adherence and the reasons behind this problem in order to orchestrate subsequent interventions. This paper reviews both subjective and objective medication adherence measures, including direct measures, those involving secondary database analysis, electronic medication packaging (EMP) devices, pill count, and clinician assessments and self-report. Subjective measures generally provide explanations for patient's nonadherence whereas objective measures contribute to a more precise record of patient's medication-taking behavior. While choosing a suitable approach, researchers and healthcare professionals should balance the reliability and practicality, especially cost effectiveness, for their purpose. Meanwhile, because a perfect measure does not exist, a multimeasure approach seems to be the best solution currently.

Identification of validated questionnaires to measure adherence to pharmacological antihypertensive treatments

BACKGROUND

Low adherence to pharmacological treatments is one of the factors associated with poor blood pressure control. Questionnaires are an indirect measurement method that is both economic and easy to use. However, questionnaires should meet specific criteria, to minimize error and ensure reproducibility of results. Numerous studies have been conducted to design questionnaires that quantify adherence to pharmacological antihypertensive treatments. Nevertheless, it is unknown whether questionnaires fulfil the minimum requirements of validity and reliability. The aim of this study was to compile validated questionnaires measuring adherence to pharmacological antihypertensive treatments that had at least one measure of validity and one measure of reliability.

METHODS

A literature search was undertaken in PubMed, the Excerpta Medica Database (EMBASE), and the Latin American and Caribbean Health Sciences Literature database (Literatura Latino-Americana e do Caribe em Ciências da Saúde [LILACS]). References from included articles were hand-searched. The included papers were all that were published in English, French, Portuguese, and Spanish from the beginning of the database's indexing until July 8, 2013, where a validation of a questionnaire (at least one demonstration of the validity and at least one of reliability) was performed to measure adherence to antihypertensive pharmacological treatments.

RESULTS

A total of 234 potential papers were identified in the electronic database search; of these, 12 met the eligibility criteria. Within these 12 papers, six questionnaires were validated: the Morisky-Green-Levine; Brief Medication Questionnaire; Hill-Bone Compliance to High Blood Pressure Therapy Scale; Morisky Medication Adherence Scale; Treatment Adherence Questionnaire for Patients with Hypertension (TAQPH); and Martín-Bayarre-Grau. Questionnaire length ranged from four to 28 items. Internal consistency, assessed by Cronbach's α, varied from 0.43 to 0.889. Additional statistical techniques utilized to assess the psychometric properties of the questionnaires varied greatly across studies.

CONCLUSION

At this stage, none of the six questionnaires included could be considered a gold standard. However, this revision will assist health professionals in the selection of the most appropriate tool for their individual circumstances.

Renal denervation of the native kidneys for drug-resistant hypertension after kidney transplantation

There is a strong rationale for renal denervation (RDN) of the native kidneys in kidney transplant recipients with treatment-resistant hypertension. We present a patient with a stable graft function, who underwent RDN for posttransplant therapy-resistant hypertension (24-h ambulatory blood pressure measurement (ABPM) 143/89 mmHg, while compliantly using five different antihypertensive agents). After RDN, BP measurements and orthostatic complaints required withdrawal of two antihypertensive agents and halving a third. At 6 months, ABPM was 134/84 mmHg and allograft function remained unchanged. This case calls for designing well-designed prospective studies on RDN in kidney transplant recipients.

Measuring self-care in patients with hypertension: a systematic review of literature

BACKGROUND

High blood pressure (HBP) self-care is critical for the control of HBP. Adequate measurement of HBP self-care is a necessary first step toward ameliorating the global pandemic of HBP.

OBJECTIVE

The aims of this study were to identify, describe, and critique existing HBP self-care instruments. The degree of adequacy of these instruments was evaluated against well-established behavioral guidelines for HBP care.

METHODS

This review was limited to articles published in English before October 2012. In addition, the following criteria were used: (1) the study described the validity and/or the reliability of a self-care/self-management instrument and (2) the study targeted patients with hypertension. Electronic database searches identified 1701 potentially relevant articles. Two authors reviewed the titles and the abstracts of all the retrieved articles independently. On the basis of the inclusion and the exclusion criteria, as well as cross-referencing, 29 articles were included in this review.

RESULTS

From the 29 articles, 19 unique HBP self-care instruments were identified (some were modified or translated versions of an original measure). Medication taking, a key domain of HBP self-care, was the main focus of 12 of the 19 instruments. Other key domains of HBP self-care were often missing or omitted. Seven instruments measured multiple dimensions of self-care; however, these either failed to capture all the main HBP self-care domains or had poor psychometric profiles. Nineteen of the 29 articles reported both validity and reliability, with varying degrees of rigor.

CONCLUSIONS

The current assessment tools do not capture all the critical elements of HBP self-care. The few instruments that attempted to measure the multiple behavioral dimensions of HBP self-care failed to report adequate levels of psychometric properties of those domains because of their incompleteness. Challenges remain in translating the HBP self-care guidelines into effective intervention and relevant assessment tools. Developing a valid and reliable instrument that captures the multidimensional nature of HBP self-care is urgently needed.

Impact of baseline patient characteristics on interventions to reduce diabetes distress: the role of personal conscientiousness and diabetes self-efficacy

AIMS

To improve patient-centred care by determining the impact of baseline levels of conscientiousness and diabetes self-efficacy on the outcomes of efficacious interventions to reduce diabetes distress and improve disease management.

METHODS

Adults with Type 2 diabetes with diabetes distress and self-care problems (N = 392) were randomized to one of three distress reduction interventions: computer-assisted self-management; computer-assisted self-management plus problem-solving therapy; and health education. The baseline assessment included conscientiousness and self-efficacy, demographics, diabetes status, regimen distress, emotional burden, medication adherence, diet and physical activity. Changes in regimen distress, emotional burden and self-care between baseline and 12 months were recorded and ancova models assessed how conscientiousness and self-efficacy qualified the significant improvements in distress and management outcomes.

RESULTS

Participants with high baseline conscientiousness displayed significantly larger improvements in medication adherence and emotional burden than participants with low baseline conscientiousness. Participants with high baseline self-efficacy showed greater improvements in diet, physical activity and regimen distress than participants with low baseline self-efficacy. The impact of conscientiousness and self-efficacy were independent of each other and occurred across all three intervention groups. A significant interaction indicated that those with both high self-efficacy and high conscientiousness at baseline had the biggest improvement in physical activity by 12 months.

CONCLUSIONS

Both broad personal traits and disease-specific expectations qualify the outcomes of efficacious interventions. These findings reinforce the need to change from a one-size-fits-all approach to diabetes interventions to an approach that crafts clinical interventions in ways that fit the personal traits and skills of individual people.

Minimal intervention needed for change: definition, use, and value for improving health and health research

Much research focuses on producing maximal intervention effects. This has generally not resulted in interventions being rapidly or widely adopted or seen as feasible given resources, time, and expertise constraints in the majority of real-world settings. We present a definition and key characteristics of a minimum intervention needed to produce change (MINC). To illustrate use of a MINC condition, we describe a computer-assisted, interactive minimal intervention, titled Healthy Habits, used in three different controlled studies and its effects. This minimal intervention produced modest to sizable health behavior and psychosocial improvements, depending on the intensity of personal contacts, producing larger effects at longer-term assessments. MINC comparison conditions could help to advance both health care and health research, especially comparative effectiveness research. Policy and funding implications of requiring an intervention to be demonstrated more effective than a simpler, less costly MINC alternative are discussed.

Reductions in regimen distress are associated with improved management and glycemic control over time

OBJECTIVE Cross-sectional and longitudinal associations among regimen distress (RD), self-management, and glycemic control were undertaken to explore mechanisms of operation among these variables. RESEARCH DESIGN AND METHODS In a behavioral randomized control trial (RCT) to reduce RD, 392 adults with type 2 diabetes were assessed for RD, diet, exercise, medication adherence, and HbA1c at baseline and at 4 and 12 months. Associations among RD, self-management, and HbA1c were examined in cross-sectional analyses at baseline, in prospective analyses using baseline values to predict change over time, and in time-varying analyses. RESULTS At baseline, greater RD and poorer medication adherence were independently associated with higher HbA1c (P = 0.05 and P < 0.001, respectively), and greater RD was associated with poorer medication adherence (P = 0.03). No consistent pattern of significant prospective associations was found. Significant time-varying findings showed that decreases in RD were associated with improvements in medication adherence (P < 0.01), physical activity (P < 0.001), and HbA1c (P = 0.02) over time following intervention. Changes in self-management were not associated with changes in HbA1c over time. CONCLUSIONS In the context of an RCT to reduce distress, RD, self-management, and HbA1c were interrelated in cross-sectional and time-varying analyses. Decreases in RD were associated with improvements in both self-management and HbA1c over 12 months. Findings point to the complex and likely multifaceted pathways of association among these key constructs, with results indicating significant linkages between RD and both self-management and glycemic control over time.

Factors associated with good glycemic control among patients with type 2 diabetes mellitus

AIMS/INTRODUCTION

The aim of the present study was to determine the status of glycemic control and identify factors associated with good glycemic control among diabetic patients treated at primary health clinics.

MATERIALS AND METHODS

A systematic random sample of 557 patients was selected from seven clinics in the Hulu Langat District. Data were collected from patients' medication records, glycemic control tests and structured questionnaires. Logistic regression analysis was carried out to predict factors associated with good glycemic control.

RESULTS

Variables associated with good glycemic control included age (odds ratio 1.033; 95% confidence interval 1.008-1.059) and duration of diabetes mellitus (odds ratio 0.948; 95% confidence interval 0.909-0.989). Compared with the patients who were receiving a combination of insulin and oral antidiabetics, those receiving monotherapy (odds ratio 4.797; 95% confidence interval 1.992-11.552) and a combination of oral antidiabetics (odds ratio 2.334; 95% confidence interval 1.018-5.353) were more likely to have good glycemic control. In the present study, the proportion of patients with good glycemic control was lower than that in other published studies. Older patients with a shorter duration of diabetes who were receiving monotherapy showed better glycemic control.

CONCLUSIONS

Although self-management behavior did not appear to influence glycemic control, diabetic patients should be consistently advised to restrict sugar intake, exercise, stop smoking and adhere to medication instructions. Greater effort by healthcare providers in the primary health clinics is warranted to help a greater number of patients achieve good glycemic control.

REDEEM: a pragmatic trial to reduce diabetes distress

OBJECTIVE

To compare three interventions to reduce diabetes distress (DD) and improve self-management among non-clinically depressed adults with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

In REDEEM, 392 adults with T2DM and DD were randomized to computer-assisted self-management (CASM), CASM plus DD-specific problem solving (CAPS), or a computer-administered minimal supportive intervention. Primary outcomes were Diabetes Distress Scale (DDS) total, the Emotional Burden (EB) and Regimen Distress (RD) DDS subscales, and diet, exercise, and medication adherence.

RESULTS

Significant and clinically meaningful reductions in DD (DDS, EB, and RD) and self-management behaviors occurred in all three conditions (P < 0.001), with no significant between-group differences. There was, however, a significant group × baseline distress interaction (P < 0.02), in which patients with high baseline RD in the CAPS condition displayed significantly larger RD reductions than those in the other two conditions. RD generated the most distress and displayed the greatest distress reduction as a result of intervention. The pace of DD reduction varied by patient age: older patients demonstrated significant reductions in DD early in the intervention, whereas younger adults displayed similar reductions later. Reductions in DD were accompanied by significant improvements in healthy eating, physical activity, and medication adherence, although not by change in HbA1c.

CONCLUSIONS

DD is malleable and highly responsive to intervention. Interventions that enhance self-management also reduce DD significantly, but DD-specific interventions may be necessary for patients with high initial levels of DD. Future research should identify the minimal, most cost-effective interventions to reduce DD and improve self-management.

Evaluation of a community health worker pilot intervention to improve diabetes management in Bangladeshi immigrants with type 2 diabetes in New York City

PURPOSE

The purpose of this study is to explore the impact and feasibility of a pilot Community Health Worker (CHW) intervention to improve diabetes management among Bangladeshi-American individuals with type 2 diabetes living in New York City.

METHODS

Participants were recruited at clinic- and community-based venues. The intervention consisted of 6 monthly, CHW-facilitated group sessions on topics related to management of diabetes. Surveys were collected at baseline and follow-up time points. Study outcomes included clinical, behavioral, and satisfaction measures for participants, as well as qualitative measures from CHWs.

RESULTS

Improvements were seen in diabetes knowledge, exercise and diet to control diabetes, frequency of checking feet, medication compliance, and self-efficacy of health and physical activity from baseline to 12 months. Additionally, there were decreases in A1C, weight, and body mass index. Program evaluation revealed a high acceptability of the intervention, and qualitative findings indicated that CHWs helped overcome barriers and facilitated program outcomes through communal concordance, trust, and leadership.

CONCLUSIONS

The intervention demonstrated high acceptability and suggested efficacy in improving diabetes management outcomes among Bangladeshi immigrants in an urban setting. The US Bangladeshi population will continue to increase, and given the high rates of diabetes, as well as linguistic and economic barriers faced by this community, effective and culturally tailored health interventions are needed to overcome barriers and provide support for diabetes management.

Development and evaluation of a self-report tool to predict low pharmacy refill adherence in elderly patients with uncontrolled hypertension

OBJECTIVE

To develop and evaluate a short self-report tool to predict low pharmacy refill adherence in older patients with uncontrolled hypertension.

DESIGN

Cross-sectional analysis of survey and administrative data from the Cohort Study of Medication Adherence Among Older Adults (CoSMO).

PARTICIPANTS

A total of 394 adults with uncontrolled blood pressure; mean ± SD age was 76.6 ± 5.6 years, 33.0% were black, 66.0% were women, and 23.4% had a low medication possession ratio (MPR).

MEASUREMENTS AND MAIN RESULTS

We considered 164 self-reported candidate items for development of a prediction rule for low (less than 0.8) versus high (0.8 or more) MPR from pharmacy refill data. Risk prediction models were evaluated by using best subsets analyses, and the final model was chosen based on clinical relevance and model parsimony. Bootstrap simulations assessed internal validity. The performance of the final four-item model was compared to the eight-item Morisky Medication Adherence Scale (MMAS-8) and the nine-item Hill-Bone Compliance Scale. The four-item self-report tool for predicting pharmacy refill adherence showed moderate discrimination (C statistic 0.704, 95% confidence interval [CI], 0.683-0.714) and good model fit (Hosmer-Lemeshow χ² = 1.238, p=0.743). Sensitivity and specificity were 67.4% and 67.8%, respectively. The concordance (C) statistics for MMAS-8 and the Hill-Bone Compliance Scale were lower at 0.665 (95% CI 0.632-0.683) and 0.660 (95% CI 0.622-0.674), respectively.

CONCLUSION

A four-item self-report tool moderately discriminated low from high pharmacy refill adherers, and its test performance was comparable with existing eight- and nine-item adherence scales. Parsimonious self-report tools predicting low pharmacy refill in patients with uncontrolled blood pressure could facilitate hypertension management in the elderly.

The effectiveness of medical assistant health coaching for low-income patients with uncontrolled diabetes, hypertension, and hyperlipidemia: protocol for a randomized controlled trial and baseline characteristics of the study population

BACKGROUND

Many patients with chronic disease do not reach goals for management of their conditions. Self-management support provided by medical assistant health coaches within the clinical setting may help to improve clinical outcomes, but most studies to date lack statistical power or methodological rigor. Barriers to large scale implementation of the medical assistant coach model include lack of clinician buy-in and the absence of a business model that will make medical assistant health coaching sustainable. This study will add to the evidence base by determining the effectiveness of health coaching by medical assistants on clinical outcomes and patient self-management, by assessing the impact of health coaching on the clinician experience, and by examining the costs and potential savings of health coaching.

METHODS/DESIGN

This randomized controlled trial will evaluate the effectiveness of clinic-based medical assistant health coaches to improve clinical outcomes and self-management skills among low-income patients with uncontrolled type 2 diabetes, hypertension, or hyperlipidemia. A total of 441 patients from two San Francisco primary care clinics have been enrolled and randomized to receive a health coach (n = 224) or usual care (n = 217). Patients participating in the health coaching group will receive coaching for 12 months from medical assistants trained as health coaches. The primary outcome is a change in hemoglobin A1c, systolic blood pressure, or LDL cholesterol among patients with uncontrolled diabetes, hypertension and hyperlipidemia, respectively. Self-management behaviors, perceptions of the health care team and clinician, BMI, and chronic disease self-efficacy will be measured at baseline and after 12 months. Clinician experience is being assessed through surveys and qualitative interviews. Cost and utilization data will be analyzed through cost-predictive models.

DISCUSSION

Medical assistants are an untapped resource to provide self-management support for patients with uncontrolled chronic disease. Having successfully completed recruitment, this study is uniquely poised to assess the effectiveness of the medical assistant health coaching model, to describe barriers and facilitators to implementation, and to develop a business case for sustainability.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT-01220336.

Medication adherence in patients with type 2 diabetes mellitus treated at primary health clinics in Malaysia

PURPOSE

Diabetes mellitus is a growing global health problem that affects patients of all ages. Even though diabetes mellitus is recognized as a major chronic illness, adherence to antidiabetic medicines has often been found to be unsatisfactory. This study was conducted to assess adherence to medications and to identify factors that are associated with nonadherence in type 2 diabetes mellitus (T2DM) patients at Primary Health Clinics of the Ministry of Health in Malaysia.

MATERIALS AND METHODS

The cross-sectional survey was carried out among T2DM patients to assess adherence to medication in primary health clinics. Adherence was measured by using the Medication Compliance Questionnaire that consists of a total of seven questions. Other data, such as patient demographics, treatment, outcome, and comorbidities were also collected from patient medical records.

RESULTS

A total of 557 patients were recruited in the study. Approximately 53% of patients in the study population were nonadherent. Logistic regression analysis was performed to predict the factors associated with nonadherence. Variables associated with nonadherence were age, odds ratio 0.967 (95% confidence interval [CI]: 0.948-0.986); medication knowledge, odds ratio 0.965 (95% CI: 0.946-0.984); and comorbidities, odds ratio 1.781 (95% CI: 1.064-2.981).

CONCLUSION

Adherence to medication in T2DM patients in the primary health clinics was found to be poor. This is a cause of concern, because nonadherence could lead to a worsening of disease. Improving medication knowledge by paying particular attention to different age groups and patients with comorbidities could help improve adherence.

Twelve-month outcomes of an Internet-based diabetes self-management support program

OBJECTIVE

Internet-based programs offer potential for practical, cost-effective chronic illness self-management programs.

METHODS

We report 12-month results of an Internet-based diabetes self-management program, with and without additional support, compared to enhanced usual care in a 3-arm practical randomized trial. Patients (n=463) were randomized: 77.3% completed 12-month follow-up. Primary outcomes were changes in health behaviors of healthy eating, physical activity, and medication taking. Secondary outcomes were hemoglobin A1c, body mass index, lipids, blood pressure, and psychosocial factors.

RESULTS

Internet conditions improved health behaviors significantly vs. usual care over the 12-month period (d for effect size=.09-.16). All conditions improved moderately on biological and psychosocial outcomes. Latinos, lower literacy, and higher cardiovascular disease risk patients improved as much as other participants.

CONCLUSIONS

The Internet intervention meets the reach and feasibility criteria for a potentially broad public health impact. However, 12-month magnitude of effects was small, suggesting that different or more intensive approaches are necessary to support long-term outcomes. Research is needed to understand the linkages between intervention and maintenance processes and downstream outcomes.

PRACTICE IMPLICATIONS

Automated self-management interventions should be tailored and integrated into primary care; maintenance of patient self-management can be enhanced through links to community resources.

Medication adherence among hypertensive patients of primary health clinics in Malaysia

PURPOSE

Poor adherence to prescribed medications is a major cause for treatment failure, particularly in chronic diseases such as hypertension. This study was conducted to assess adherence to medications in patients undergoing hypertensive treatment in the Primary Health Clinics of the Ministry of Health in Malaysia. Factors affecting adherence to medications were studied, and the effect of nonadherence to blood pressure control was assessed.

PATIENTS AND METHODS

This was a cross-sectional study to assess adherence to medications by adult patients undergoing hypertensive treatment in primary care. Adherence was measured using a validated survey form for medication adherence consisting of seven questions. A retrospective medication record review was conducted to collect and confirm data on patients' demographics, diagnosis, treatments, and outcomes.

RESULTS

Good adherence was observed in 53.4% of the 653 patients sampled. Female patients were found to be more likely to adhere to their medication regime, compared to their male counterparts (odds ratio 1.46 [95% confidence intervals [CI]: 1.05-2.04; P < 0.05]). Patients in the ethnic Chinese were twice as likely (95% CI: 1.14-3.6; P < 0.05) to adhere, compared to those in the Indian ethnic group. An increase in the score for medicine knowledge was also found to increase the odds of adherence. On the other hand, increasing the number of drugs the patient was taking and the daily dose frequencies of the medications prescribed were found to negatively affect adherence. Blood pressure control was also found to be worse in noncompliers.

CONCLUSION

The medication adherence rate was found to be low among primary care hypertensive patients. A poor adherence rate was found to negatively affect blood pressure control. Developing multidisciplinary intervention programs to address the factors identified is necessary to improve adherence and, in turn, to improve blood pressure control.

Psychometric evaluation of hill-bone medication adherence subscale

PURPOSE

Medication adherence is an essential part of the management and control of high blood pressure (HBP). Although the Hill-Bone Medication Adherence (HBMA) scale is one of the most frequently used instruments for measuring HBP medication adherence, the psychometric properties of the scale have never been tested among Korean Americans, a population that experiences a disproportionately high prevalence of HBP. Therefore, the objective of this study is to validate a Korean version of the HBMA subscale (HBMA-K).

METHOD

We used two, independent samples of Korean Americans (KAs) (combined n = 525) who participated in community-based intervention trials for HBP control. To develop the HBMA-K, the original scale was translated into Korean and then back translated into English. Reliability was assessed by calculating the Cronbach's alpha. Exploratory factor analysis (EFA) was done to assess construct validity. We also calculated the Pearson's correlation coefficients between the scale and theoretically driven variables such as blood pressure, knowledge, and HBP belief to test concurrent validity.

RESULTS

The EFA revealed a one-factor solution with eight items, explaining 35.4% of the variance. Cronbach's alpha was .80. The 8-item HBMA-K scale was significantly associated with systolic blood pressure (BP) (r = .18, p < .01), diastolic BP (r = .24, p < .01), HBP knowledge (r = -.13, p < .01), and HBP belief score (r = -.18, p < .05).

CONCLUSIONS

The 8-item HBMA-K scale is a valid and reliable instrument for measuring medication adherence among KAs with HBP. It can be easily administered at community and clinical settings to screen hypertensive patients with low medication adherence.

Engagement in a diabetes self-management website: usage patterns and generalizability of program use

Background

Increased access to the Internet and the availability of efficacious eHealth interventions offer great promise for assisting adults with diabetes to change and maintain health behaviors. A key concern is whether levels of engagement in Internet programs are sufficient to promote and sustain behavior change.

Objective

This paper used automated data from an ongoing Internet-based diabetes self-management intervention study to calculate various indices of website engagement. The multimedia website involved goal setting, action planning, and self-monitoring as well as offering features such as “Ask an Expert” to enhance healthy eating, physical activity, and medication adherence. We also investigated participant characteristics associated with website engagement and the relationship between website use and 4-month behavioral and health outcomes.

Methods

We report on participants in a randomized controlled trial (RCT) who were randomized to receive (1) the website alone (n = 137) or (2) the website plus human support (n = 133) that included additional phone calls and group meetings. The website was available in English and Spanish and included features to enhance engagement and user experience. A number of engagement variables were calculated for each participant including number of log-ins, number of website components visited at least twice, number of days entering self-monitoring data, number of visits to the “Action Plan” section, and time on the website. Key outcomes included exercise, healthy eating, and medication adherence as well as body mass index (BMI) and biological variables related to cardiovascular disease risk.

Results

Of the 270 intervention participants, the average age was 60, the average BMI was 34.9 kg/m², 130 (48%) were female, and 62 (23%) self-reported Latino ethnicity. The number of participant visits to the website over 4 months ranged from 1 to 119 (mean 28 visits, median 18). Usage decreased from 70% of participants visiting at least weekly during the first 6 weeks to 47% during weeks 7 to 16. There were no significant differences between website only and website plus support conditions on most of the engagement variables. In total, 75% of participants entered self-monitoring data at least once per week. Exercise action plan pages were visited more often than medication taking and healthy eating pages (mean of 4.3 visits vs 2.8 and 2.0 respectively, P < .001). Spearman nonparametric correlations indicated few significant associations between patient characteristics and summary website engagement variables, and key factors such as ethnicity, baseline computer use, age, health literacy, and education were not related to use. Partial correlations indicated that engagement, especially in self-monitoring, was most consistently related to improvement in healthy eating (r = .20, P = .04) and reduction of dietary fat (r = -.31, P = .001). There was also a significant correlation between self-monitoring and improvement in exercise (r = .20, P = .033) but not with medication taking.

Conclusions

Participants visited the website fairly often and used all of the theoretically important sections, but engagement decreased over 4 months. Usage rates and patterns were similar for a wide range of participants, which has encouraging implications for the potential reach of online interventions.

Trial Registration

NCT00987285; http://clinicaltrials.gov/show/NCT00987285 (Archived by WebCite at http://www.webcitation.org/5vpe4RHTV)

Studying the use of oral contraception: a review of measurement approaches

BACKGROUND

Although oral contraception (OC) misuse is presumed to play an important role in unwanted pregnancy, research findings have often been equivocal, perhaps reflecting unaddressed inconsistencies in methodological approaches.

METHODS

Using established databases, we performed a systematic review of measurement methods for OC use using primary research reports published from January 1965 to December 2009.

RESULTS

Terminology used to describe OC use, which included "continuation," "compliance," and "adherence," differed across studies and was rarely defined. The majority of studies (n = 27 of 38, 71%) relied solely on self-report measures of OC use. Only two reports described survey or interview questions, and reliability and validity data were seldom described. More rigorous measurement methods, such as pill counts (electronic or manual), serum and urinary biomarkers, and pharmacy records, were infrequently employed. Nineteen studies simultaneously used more than one method, but only three studies compared direct and indirect methods.

CONCLUSIONS

The lack of a consistent, well-defined measurement of OC use limits our understanding of contraceptive misuse and related negative outcomes. Future research should clarify terminology, develop standardized measures, incorporate multimethod approaches with innovative methods, and publish details of measurement methods.

Outcomes of minimal and moderate support versions of an internet-based diabetes self-management support program

OBJECTIVE

Internet and other interactive technology-based programs offer great potential for practical, effective, and cost-efficient diabetes self-management (DSM) programs capable of reaching large numbers of patients. This study evaluated minimal and moderate support versions of an Internet-based diabetes self-management program, compared to an enhanced usual care condition.

RESEARCH DESIGN AND METHODS

A three-arm practical randomized trial was conducted to evaluate minimal contact and moderate contact versions of an Internet-based diabetes self-management program, offered in English and Spanish, compared to enhanced usual care. A heterogeneous sample of 463 type 2 patients was randomized and 82.5% completed a 4-month follow-up. Primary outcomes were behavior changes in healthy eating, physical activity, and medication taking. Secondary outcomes included hemoglobin A1c, body mass index, lipids, and blood pressure.

RESULTS

The Internet-based intervention produced significantly greater improvements than the enhanced usual care condition on three of four behavioral outcomes (effect sizes [d] for healthy eating = 0.32; fat intake = 0.28; physical activity= 0.19) in both intent-to-treat and complete-cases analyses. These changes did not translate into differential improvements in biological outcomes during the 4-month study period. Added contact did not further enhance outcomes beyond the minimal contact intervention.

CONCLUSIONS

The Internet intervention meets several of the RE-AIM criteria for potential public health impact, including reaching a large number of persons, and being practical, feasible, and engaging for participants, but with mixed effectiveness in improving outcomes, and consistent results across different subgroups. Additional research is needed to evaluate longer-term outcomes, enhance effectiveness and cost-effectiveness, and understand the linkages between intervention processes and outcomes.

Antihypertensive Medication Adherence Among Elderly Chinese Americans

This study explored the level of antihypertensive medication adherence and examined certain demographic attributes and influential factors in relation to antihypertensive medication nonadherence among Chinese American elders using a descriptive cross-sectional survey design. Findings revealed that 52% of the elderly Chinese Americans adhered to their antihypertensive medications. Gender, education, years of residency in the United States, years of diagnosed hypertension, and perceived safety of taking antihypertensive medications did not contribute to the differences in medication adherence. Forgetfulness, medication adverse effects, language difficulties, and cultural barriers were the influential factors that hinder antihypertensive medication adherence. Developing effective and culturally appropriate strategies for Chinese American elders is recommended.

Racial differences in medication adherence: A cross-sectional study of Medicare enrollees

BACKGROUND

Racial differences in adherence to prescribed medication regimens have been reported among the elderly. It remains unclear, however, whether these differences persist after controlling for confounding variables.

OBJECTIVE

The objective of this study was to determine whether racial differences in medication adherence between African American and white seniors persist after adjusting for demographic characteristics, health literacy, depression, and social support. We hypothesized that differences in adherence between the 2 races would be eliminated after adjusting for confounding variables.

METHODS

A survey on medication adherence was conducted using face-to-face interviews with Medicare recipients >or=65 years of age living in Chicago. Participants had to have good hearing and vision and be able to speak English to enable them to respond to questions in the survey and sign the informed-consent form. Medication adherence measures included questions about: (1) running out of medications before refilling the prescriptions; (2) following physician instructions on how to take medications; and (3) forgetting to take medications. Individual crude odds ratios (CORs) were calculated for the association between race and medication adherence. Adjusted odds ratios (AORs) were calculated using the following covariates in multivariate logistic regression analyses: race; age; sex; living with a spouse, partner, or significant other; income; Medicaid benefits; prescription drug coverage; having a primary care physician; history of hypertension or diabetes; health status; health literacy; depression; and social support.

RESULTS

Six hundred thirty-three eligible cases were identified. Of the 489 patients who responded to the survey, 450 (266 African American [59%; mean age, 78.2 years] and 184 white [41%; mean age, 76.8 years]; predominantly women) were included in the sample. The overall response rate for the survey was 77.3%. African Americans were more likely than whites to report running out of medications before refilling them (COR = 3.01; 95% CI, 1.72-5.28) and not always following physician instructions on how to take medications (COR = 2.64; 95% CI, 1.50-4.64). However, no significant difference between the races was observed in forgetting to take medications (COR = 0.90; 95% CI, 0.61-1.31). In adjusted analyses, race was no longer associated with low adherence due to refilling (AOR = 1.60; 95% CI, 0.74-3.42). However, race remained associated with not following physician instructions on how to take medications after adjusting for confounding variables (AOR = 2.49; 95% CI, 1.07-5.80).

CONCLUSION

Elderly African Americans reported that they followed physician instructions on how to take medications less frequently than did elderly whites, even after adjusting for differences in demographic characteristics, health literacy, depression, and social support.

Low medication adherence and hypertension control among adults with CKD: data from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study

BACKGROUND

Low adherence to antihypertensive medication is an important barrier to achieving blood pressure control. Few data are available for medication adherence in adults with chronic kidney disease (CKD).

STUDY DESIGN

Cross-sectional.

SETTING & PARTICIPANTS

3,936 and 9,129 participants with and without CKD using antihypertensive medication in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study, respectively. CKD was defined as albuminuria with albumin excretion>or=30 mg/g or estimated glomerular filtration rate<60 mL/min/1.73 m2.

OUTCOMES

Medication adherence and uncontrolled hypertension.

MEASUREMENTS

Medication adherence was assessed using a validated 4-item scale. Blood pressure was measured 2 times by trained staff.

RESULTS

In REGARDS participants with and without CKD, 1,426 (36.2%) and 2,421 (26.5%) had uncontrolled hypertension with blood pressure>or=140/90 mm Hg, and 2,656 (67.5%) and 5,627 (61.6%), >or=130/80 mm Hg. Also, 27.7% of those with CKD and 27.9% of those without CKD responded "yes" to ever forgetting to take their medication and 4.4% and 4.2%, respectively, responded yes to being careless about taking their medication. Also, 5.7% and 5.3% responded yes to missing taking medication when they felt better, and 4.2% and 3.6%, to missing it when they felt sick. Overall, 23.3% and 23.7% of participants with and without CKD responded yes to 1 adherence question, whereas 7.7% and 7.2%, respectively, responded yes to 2 or more adherence questions. In those with CKD, the multivariable adjusted ORs for uncontrolled hypertension (blood pressure>or=140/90 mm Hg) for individuals answering yes to 1 and 2 or more versus 0 adherence questions were 1.26 (95% CI, 1.05-1.51) and 1.49 (95% CI, 1.12-1.98), respectively. Analogous ORs for systolic/diastolic blood pressure>or=130/80 mm Hg were 1.06 (95% CI, 0.78-1.45) and 1.20 (95% CI, 0.88-1.64).

LIMITATIONS

Pharmacy fill data were not available.

CONCLUSIONS

Individuals with CKD had similarly poor medication-taking behaviors as those without CKD.

Self-efficacy, problem solving, and social-environmental support are associated with diabetes self-management behaviors

OBJECTIVE

To evaluate associations between psychosocial and social-environmental variables and diabetes self-management, and diabetes control.

RESEARCH DESIGN AND METHODS

Baseline data from a type 2 diabetes self-management randomized trial with 463 adults having elevated BMI (M = 34.8 kg/m(2)) were used to investigate relations among demographic, psychosocial, and social-environmental variables; dietary, exercise, and medication-taking behaviors; and biologic outcomes.

RESULTS

Self-efficacy, problem solving, and social-environmental support were independently associated with diet and exercise, increasing the variance accounted for by 23 and 19%, respectively. Only diet contributed to explained variance in BMI (beta = -0.17, P = 0.0003) and self-rated health status (beta = 0.25, P < 0.0001); and only medication-taking behaviors contributed to lipid ratio (total-to-HDL) (beta = -0.20, P = 0.0001) and A1C (beta = -0.21, P < 0.0001).

CONCLUSIONS

Interventions should focus on enhancing self-efficacy, problem solving, and social-environmental support to improve self-management of diabetes.

Reach and effectiveness of DVD and in-person diabetes self-management education

OBJECTIVES

To evaluate the reach and effectiveness of a diabetes self-management DVD compared to classroom-based instruction.

METHODS

A hybrid preference/randomized design was used with participants assigned to Choice v. Randomized and DVD v. Class conditions. One hundred and eighty-nine adults with type 2 diabetes participated. Key outcomes included self-management behaviours, process measures including DVD implementation and hypothesized mediators and clinical risk factors.

RESULTS

In the Choice condition, four times as many participants chose the mailed DVD as selected Class-based instruction (38.8 v. 9.4%, p<0.001). At the 6-month follow-up, the DVD produced results generally not significantly different than classroom-based instruction, but a combined Class plus DVD condition did not improve outcomes beyond those produced by the classes alone.

DISCUSSION

The DVD appears to have merit as an efficient and appealing alternative to brief classroom-based diabetes education, and the hybrid design is recommended to provide estimates of programme reach.