Patient and provider's perspective on barriers and facilitators for medication adherence among adult patients with cardiovascular diseases and diabetes mellitus in India: a qualitative evidence synthesis

Barriers to Medication Adherence Among Patients with Non-Communicable Disease in North Wollo Zone Public Hospitals: Socio-Ecologic Perspective, 2023

Background

The practice of taking medication as directed by a healthcare provider is known as medication adherence. Therefore, the application of a socio-ecological model to this study identifies multilevel factors on barriers of medication adherence on chronic non-communicable disease and provides information to develop scientific health communication interventional strategies to improve medication adherence.

Objective

This study aimed to explore barriers of medication adherence on non-communicable disease prevention and care among patients in North Wollo Zone public hospitals, northeast Ethiopia.

Methods

A phenomenological study design was carried out between February 5 and February 30, 2023. The study participants were chosen using a heterogeneous purposive sampling technique. In-depth interviews and targeted focus groups were used to gather data. The focus group discussions and in-depth interviews were captured on audio, accurately transcribed, and translated into English. Atlas TI-7 was utilized to do the thematic analysis.

Results

Four main themes, intrapersonal, interpersonal, community level, and health care related, as well as seven subthemes, financial problems, lack of family support, poor communication with healthcare providers, effects of social ceremonies, remote healthcare facility, and drug scarcity, were identified by this study. In this study participants reported that lack of knowledge about the disease and drugs were the main barrier for medication adherence. The study revealed that financial problems for medication and transportation cost were the main factor for medication adherence for non-communicable disease patients.

Conclusion

This study explored that lack of knowledge, financial problem, lack of family support, poor communication with healthcare providers, social ceremony effects, remote healthcare facility, and scarcity of drugs were barriers of medication adherence among non-communicable disease patients. In order to reduce morbidity and mortality from non-communicable diseases, it is advised that all relevant bodies look for ways to reduce medication adherence barriers for patients at every level of influence.

Metabolic syndrome burden, determinants and treatment status in an urban slum resettlement colony in Delhi, India

BACKGROUND

Metabolic syndrome (MetS) in low-resource settings contributes to accentuated risk of cardiovascular disease, including stroke. The study objective was to estimate the prevalence, determinants and treatment status of MetS in an urban slum resettlement population in Delhi, India.

METHODS

This study was conducted from February to May 2023. Multiphase sampling was conducted with 1910 individuals screened for abdominal obesity (AO), with 996 detected as having AO, of which, 400 were selected by simple random sampling and further evaluated for triglycerides (TGs), high-density lipoprotein (HDL) and fasting glucose levels.

RESULTS

Among the 400 participants detected as having AO, 211 had evidence of MetS (52.75% [95% confidence interval 47.83 to 57.62]). The most prevalent combination of MetS clustering was for all five components (AO, diabetes mellitus [DM], hypertension [HTN], low HDL and high TGs; 14.69%), followed by AO, DM and HTN (12.32%). On adjusted analysis, the odds of having MetS was found to be independently associated with increasing age (≥40 y) but not sex.

CONCLUSIONS

A high burden of MetS and suboptimal treatment status is prevalent in urban slum populations. Screening of individuals with AO, especially in those >40 y of age, can be an effective programmatic strategy for early diagnosis and management of MetS and its underlying components.

Factors Influencing Medication Adherence Among Adults Living with Diabetes and Comorbidities: a Qualitative Systematic Review

PURPOSE OF REVIEW

Medication adherence plays an important role in improving health outcomes related to diabetes and comorbidity. The potential factors influencing medication adherence and how they contribute to health behaviors have not been synthesized to date. This review synthesized qualitative studies that identified factors influencing medication adherence among adults living with diabetes and comorbidity.

RECENT FINDINGS

Twenty-eight findings were extracted and synthesized into four themes: perceived support, lack of knowledge, medication issues, and the importance of routine. The findings highlight the factors that support medication adherence and areas that can be targeted to support and promote medication adherence. The findings also support the potential role of healthcare providers in supporting people living with diabetes and comorbidity to adhere to and maintain medication regimes. Several factors were identified that are amenable to intervention within the clinical practice setting and have the potential to enhance medication adherence and improve health outcomes for people living with diabetes and comorbidities. The development of acceptable and effective interventions could have a positive effect on medication adherence and health outcomes.

Tensions in caring for chronic patients' medication adherence: A qualitative study in Cyprus

Medication adherence (MA) to recommended treatment is a multi-faceted problem and an ongoing challenge for healthcare providers (HCPs) to monitor. This qualitative study with 10 HCPs in Cyprus aims to explore HCPs' perceptions and strategies used on addressing medication non-adherence (MNA) in patients with chronic conditions. Two main themes emerged from the analysis reflecting the ways that HCPs described their reactions to MNA of their patients: (1) "Relying on information provision to improve MA" and (2) "Trying to understand patients' perspective." HCPs reported empathizing with patients and engaging in discussions to understand patients' perspective and reasons for MNA, so as to explore alternative solutions. Simultaneously, some HCPs reflected that the techniques used to improve MA are solely centered around information on medication and side-effects. HCPs experienced an internal conflict between providing patient-centered care versus using directive approaches to improve MA. Findings suggest how HCPs could thoroughly address patients' individual barriers.

Determinants of Adherence to Treatment in Type 2 Diabetic Patients: A Directed Qualitative Content Analysis Based on Pender's Health Promotion Model

Adherence to the treatment of type 2 diabetes (T2D), which includes the use of prescribed drugs, following a healthy diet, and adopting a physically active lifestyle, is important to control the disease and improve the patients' quality of life. The present study aimed to explain the determinants of adherence to treatment in patients with T2D based on Pender's Health Promotion Model (HPM). The present research used a qualitative content analysis and was based on Pender's HPM. The data were collected through in-depth semi-structured interviews with 20 T2D patients using a purposive sampling in Bandar Abbas, southern Iran. Maximum variation was considered in terms of gender, age, history of diabetes, type of drug used, education, and occupation. The data collection continued until data saturation. At the same time, the collected data were analyzed using the directed content analysis. MAXQDA 10 was used to manage codes and facilitate data analysis. The data analysis led to the extraction of 10 categories and 19 subcategories as the determinants of adherence to the treatment of T2D patients. The participants shared their experiences about personal characteristics and their ecological environment, specific cognition and emotions, and the behavioral results and experience as the determinants of adherence to T2D treatment. The categories extracted from this study in the form of HPM constructs provided a framework to explain treatment adherence. This information can help policy makers and planners in designing future programs.

Factors influencing adherence to non-communicable disease medication in India: secondary analysis of cross-sectional data from WHO - SAGE2

Background: Non-communicable diseases (NCDs) are a leading cause of death globally and disproportionately affect those in low- and middle-income countries lower-middle-income countries. Poor medication adherence among patients with NCDs is prevalent in India due to lack of initiation, missed dosing or cessation of treatment, and represents a growing healthcare and financial burden. Objective: This study aimed to identify factors influencing medication adherence in adults with NCDs in India. Methods: We performed a cross-sectional study, conducting secondary data analysis on the second wave of the World Health Organisation's 'Study on global AGEing and adult health (SAGE)', a survey that collected data from predominantly older adults across India. Bivariate analysis and multivariate logistic regression modelling were conducted to specifically interrogate the reasons for lack of initiation and cessation of treatment. Reporting of this study was informed by the STROBE guidelines. Results: The average medication adherence rate was 51% across 2,840 patients with one or more NCDs, reflecting non-initiation and lack of persistence of treatment. The strongest factor significantly predicting non-adherence to medication across these components was multimorbidity (odds ratio 0.47, 95% CI 0.40-0.56). Tobacco use (OR = 0.76, CI 0.59-0.98) and never having attended school (OR = 0.75, CI 0.62-0.92) were significantly associated with poor medication adherence (p < 0.05) while rural living (OR = 0.70, CI 0.48-1.02), feelings of anxiety (OR = 0.84, CI 0.66-1.08) and feelings of depression (OR = 0.90, CI 0.70-1.16) were factors lacking statistically significant association with medication adherence on multivariate analysis. Older age (OR = 2.02, CI 1.51-2.71) was significantly associated with improved medication adherence whilst there was a weak association between increased wealth and improved medication use. Limitations: The SAGE2 survey did not capture whether patients were taking their medication doses according to prescribed instructions-as a result our findings may under-estimate the true prevalence of medication non-adherence. Conclusion: Our analysis provides evidence that poor medication adherence in India is multifactorial, with distinct socioeconomic and health-system factors interacting to influence patient decision making. Future large-scale surveys interrogating adherence should assess all components of adherence specifically, whilst public health interventions to improve medication adherence should focus on barriers that may exist due to multimorbidity, comorbid depression and anxiety, and low educational status.

The Indian registry on current patient profiles & treatment trends in hypertension (RECORD): One year interim analysis

Background & objectives

In India, hypertension constitutes a significant health burden. This observational, non-interventional, prospective study was conducted in five centres across India to evaluate the current clinical practices for the management of hypertension.

Methods

Participants were enrolled if they were newly diagnosed with essential hypertension or had pre-existing hypertension and were on the same therapeutic plan for the previous three months. At baseline, three months, six months, and one year, information on the patient and their treatment regimen was documented, and their quality of life (QoL) was evaluated.

Results

A total of 2000 individuals were enrolled in this study, with a mean age of 54.45 yr. Of these, 55.7 per cent (n=1114) were males, and 957 (47.85%) were newly diagnosed with hypertension, while 1043 (52.15%) had pre-existing hypertension. Stage 2 hypertension (systolic blood pressure (BP) >140 or diastolic BP ≥90 mmHg) accounted for more than 70 per cent of the participants (70.76% of pre-existing and 76.29% of newly diagnosed); the average duration of pre-existing hypertension was 68.72 months. Diabetes (31.6%) and dyslipidaemia (15.8%) were the most common comorbidities. In 43.3 per cent of the participants, monotherapy was used, and in 56.7 per cent (70.55% fixed-dose combination), combination therapy was used. Telmisartan (31.6%), amlodipine (35.2%), and a combination of the two (27.1%) were the most commonly prescribed treatment regimens. At three months, six months, and one year, treatment modifications were observed in 1.4, 1.05, and 0.23 per cent of the participants receiving monotherapy and 2.74, 4.78 and 0.35 per cent receiving combination therapy, respectively. In both groups, the proportion of individuals with controlled hypertension (≤140/90 mmHg) increased by more than 30 per cent after a year. At one year, physical and emotional role functioning, social functioning, and health improved considerably.

Interpretation & conclusions

Combination therapy for hypertension is increasingly preferred at the time of initial diagnosis. The efficacy, safety, and tolerance of the recommended medications were reflected by improvements in the QoL and the minimal changes in the therapeutic strategy required.

Interventions to promote medication adherence for chronic diseases in India: a systematic review

Introduction

Cost-effective interventions that improve medication adherence are urgently needed to address the epidemic of non-communicable diseases (NCDs) in India. However, in low- and middle-income countries like India, there is a lack of analysis evaluating the effectiveness of adherence improving strategies. We conducted the first systematic review evaluating interventions aimed at improving medication adherence for chronic diseases in India.

Methods

A systematic search on MEDLINE, Web of Science, Scopus, and Google Scholar was conducted. Based on a PRISMA-compliant, pre-defined methodology, randomized control trials were included which: involved subjects with NCDs; were located in India; used any intervention with the aim of improving medication adherence; and measured adherence as a primary or secondary outcome.

Results

The search strategy yielded 1,552 unique articles of which 22 met inclusion criteria. Interventions assessed by these studies included education-based interventions (n = 12), combinations of education-based interventions with regular follow up (n = 4), and technology-based interventions (n = 2). Non-communicable diseases evaluated commonly were respiratory disease (n = 3), type 2 diabetes (n = 6), cardiovascular disease (n = 8) and depression (n = 2).

Conclusions

Although the vast majority of primary studies supporting the conclusions were of mixed methodological quality, patient education by CHWs and pharmacists represent promising interventions to improve medication adherence, with further benefits from regular follow-up. There is need for systematic evaluation of these interventions with high quality RCTs and their implementation as part of wider health policy.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022345636, identifier: CRD42022345636.

Socio-personal factors affecting adherence to treatment in patients with type 2 diabetes: A systematic review and meta-analysis

PURPOSE

The purpose of study was to identify the socio-personal factors affecting adherence to the treatment of patients with type 2 diabetes.

METHODS

Cross-sectional articles were extracted from databases such as Web of Science, PubMed, Elsevier. A meta-analysis was performed using integrated odds ratios (OR) and 95% confidence interval (CIs) for age, BMI, depression, educational level, gender, employment status, marital status, smoking status. STATA 12.0 was used to estimate pooled RR in definite subgroups. The quality of the studies included was evaluated using the STROBE checklist.

RESULTS

Thirty-one studies out of 7407 extracted articles were finally selected for the meta-analysis. The results showed that younger people had a 17% higher risk than older people, smokers had a 22% higher risk than non-smokers, and the employed had a 15% higher risk of non-adherence to treatment.

CONCLUSION

In conclusion, older age, smoking and employment can lead to non-adherence to T2D treatment. Interventions are suggested to be made besides common health care considering the socio-personal features on type 2 diabetes patients' treatment adherence.

Cardiometabolic Patient-Related Factors Influencing the Adherence to Lifestyle Changes and Overall Treatment: A Review of the Recent Literature

It is well acknowledged that most of the modifiable risk factors for Cardiovascular Diseases (CVDs) can be averted through lifestyle modifications beyond medication adherence. This review aims to critically evaluate the cardiometabolic (CM) patient-related factors that influence the adherence to lifestyle changes studied alone and/or in combination with medication. A comprehensive literature search of PubMed articles from 2000 to 2023 retrieved 379 articles. After removing the articles which were not relevant, a total of 28 cross-sectional studies was chosen (12 qualitative, and 16 quantitative). The findings confirmed that five groups of factors influence patients' adherence to overall treatment: (1) health beliefs, knowledge, and perceptions regarding the risks and challenges of disease and medication intake along with adherence process perceptions; (2) self-concept; (3) emotions; (4) patient-healthcare providers relationship/communication and (5) social and cultural interactions. It is worth mentioning that cultural issues, such as culinary particularities, ethnic identity, social life as well as patients' skills and abilities, play a profound role in the effectiveness of the recommended lifestyle modifications beyond the aforementioned common factors. The need for clear-cut culturally adapted guidelines along with personalized advice from physicians is imperative as it could improve patients' self-efficacy. These socio-psychological factors should be seriously considered as a means to increase the effectiveness of future community prevention programs.

"I just wanted to speak to someone- and there was no one…": using Burden of Treatment Theory to understand the impact of a novel ATMP on early recipients

BACKGROUND

Advanced therapy medicinal products such as Chimeric antigen receptor T-cell therapy offer ground-breaking opportunities for the treatment of various cancers, inherited diseases, and chronic conditions. With development of these novel therapies continuing to increase it's important to learn from the experiences of patients who were among the first recipients of ATMPs. In this way we can improve the clinical and psychosocial support offered to early patient recipients in the future to support the successful completion of treatments and trials.

STUDY DESIGN

We conducted a qualitative investigation informed by the principles of the key informant technique to capture the experience of some of the first patients to experience CAR-T therapy in the UK. A directed content analysis was used to populate a theoretical framework informed by Burden of Treatment Theory to determine the lessons that can be learnt in supporting their care, support, and ongoing self-management.

RESULTS

A total of five key informants were interviewed. Their experiences were described within the three domains of the burden of treatment framework; (1) The health care tasks delegated to patients, Participants described the frequency of follow-up and the resources involved, the esoteric nature of the information provided by clinicians; (2) Exacerbating factors of the treatment, which notably included the lack of understanding of the clinical impacts of the treatment in the broader health service, and the lack of a peer network to support patient understanding; (3) Consequences of the treatment, in which they described the anxiety induced by the process surrounding their selection for treatment, and the feeling of loneliness and isolation at being amongst the very first recipients.

CONCLUSIONS

If ATMPs are to be successfully introduced at the rates forecast, then it is important that the burden placed on early recipients is minimised. We have discovered how they can feel emotionally isolated, clinically vulnerable, and structurally unsupported by a disparate and pressured health service. We recommend that where possible, structured peer support be put in place alongside signposting to additional information that includes the planned pattern of follow-up, and the management of discharged patients would ideally accommodate individual circumstances and preferences to minimize the burden of treatment.

Comparing Medication Non-adherence in Cardiovascular Disease Patients at Public and Private Hospitals in Peshawar: A Cross-Sectional Study of Prevalence and Contributing Factors

Introduction The incidence of cardiovascular diseases continues to increase, becoming one of the leading causes of mortality globally. The proper use of medication can greatly reduce the death rate by slowing the progression of the disease. Yet, many patients struggle with following their medication regimen due to various reasons. Effective treatment management relies on patients' self-care and understanding of their illness and medications, which can impact their adherence to taking their prescribed drugs. The objective of the study was to determine the prevalence of medication non-compliance among patients in two public and private tertiary care hospitals in Peshawar and to identify the factors that contribute to this behavior. Material and methods A comparative cross-sectional study design was employed for the research. The study was conducted at Hayatabad Medical Complex and Rehman Medical Institute in Peshawar, as these two hospitals provide care for a significant proportion of cardiovascular disease patients in the area. To assess adherence, a quantitative scale was devised with scores of 8 considered high adherence, scores between 6 and 7 considered medium adherence, and scores below 6 considered low adherence. The factors impacting medication non-adherence were analyzed using a self-administered questionnaire, which was developed following a preliminary study conducted at both hospitals. Results In total, 168 eligible patients from the two hospitals were given the questionnaire. Out of these patients, 107 (63.7%) were male, and 61 (36.3%) were female, with ages ranging from 19 to 84 and a mean age of 55.33. The level of medication adherence was calculated among the participants, with 20.2% reporting high adherence, 22.6% reporting medium adherence, and 57.1% reporting low adherence. The results showed that monthly income (p = 0.006), the presence of co-morbidities (p = 0.002), and the fear of addiction to medication (p = 0.048) were the main factors influencing medication adherence. In regression analysis with high adherence as the reference category and a 95% confidence interval, hospital affiliation was found to be significantly associated with adherence levels. Conclusions The study found that medication adherence among cardiovascular disease patients in private tertiary care hospitals is generally high. However, the level of adherence was seen to be impacted by the patient's monthly income. In light of this, the government should implement programs to reduce the cost of healthcare provision and increase affordability for patients.

Medication adherence and environmental barriers to self-care practice among people with diabetes: A cross-sectional study in a lifestyle clinic in eastern India

Objective

The study was conducted to estimate the prevalence of non-adherence to medications among patients with type 2 diabetes attending a lifestyle clinic in a tertiary care hospital in West Bengal, India; to identify the environmental barriers to self-care practices, including diet, exercise, glucose testing and medication; and to identify the socio-demographic and environmental determinants of medication non-adherence.

Methods

A cross-sectional study was performed among the patients with type 2 diabetes taking oral hypoglycemic drugs and attending a lifestyle clinic of a teaching hospital in 2021. The participants were interviewed in clinical settings via a structured questionnaire in the local language. Medication adherence was assessed with Morisky Medication Adherence Scale-8 (MMAS), and environmental barriers were assessed with the Environmental Barrier Assessment Scale (EBAS).

Results

Among 178 participants, a high level of adherence (MMAS score 8.0) was found among 3 (1.7%) participants, and moderate adherence (MMAS score 6.0 to 7.75) was found among 67 (37.6%; 95% CI 30.3%, 44.9%) participants. The prevalence of non-adherence was 60.7% (95% CI: 53.4%, 68.0%). The overall mean barrier score was 134 (SD 13). All environmental barrier components were distributed equally among the predictor variables except the diet score, which was lower among men (mean difference 1.3; 95% CI: 0.04, 2.5) and people with higher education (mean difference 1.8; 95% CI: 0.6, 3.1).

Conclusion

The study indicated poor adherence to OHA in this population. Barriers to self-care practice and medication adherence were observed acrross all socio-economic strata. Poor medication adherence poses a major challenge to clinicians and public health experts in achieving treatment goals.