Medication adherence: a complex behavior of medication and illness beliefs

Scoring, Clinical Utility, and Psychometric Properties of the In-Home Medication Management Performance Evaluation (HOME-Rx)

IMPORTANCE

Forty percent to 75% of community-dwelling older adults are not able to adhere to their medication routine. A medication management assessment can correctly identify the reasons for nonadherence and the barriers contributing to it.

OBJECTIVE

To further develop the HOME-Rx, an in-home medication management assessment, by modifying scoring metrics, improving clinical utility, and establishing psychometric properties.

DESIGN

In Phase 1, the scoring metrics were modified, and the clinical procedures were evaluated. In Phase 2, the psychometric properties were established.

SETTING

The homes of older adults.

PARTICIPANTS

Older adults who took three or more medications, managed their own medications, and lived in their own home were eligible. Older adults with cognitive impairment were ineligible.

OUTCOMES AND MEASURES

We assessed concurrent validity with the Performance Assessment for Self-Care Skills (PASS) and Medication Management Instrument for Deficiencies in the Elderly (MedMaIDE) and established interrater reliability.

RESULTS

The PASS was positively correlated with the HOME-Rx Performance and Safety subscales; the MedMaIDE was negatively correlated with the HOME-Rx Performance subscale and positively correlated with the Barriers subscale. Interrater reliability was excellent (ICCs = .87-1.00).

CONCLUSIONS AND RELEVANCE

All relationships were as predicted: The HOME-Rx is a valid and reliable performance-based assessment that provides clinicians and researchers with a measure of older adults' actual medication management ability in the home using their medications. The results can potentially be used to guide treatment planning and improve medication management.

WHAT THIS ARTICLE ADDS

Occupational therapy practitioners can use the HOME-Rx to adequately determine performance problems, safety concerns, and environmental barriers and potentially to guide treatment planning and improve medication management for older adults.

Better understanding the influence and complexity of beliefs on medication adherence in asthma

OBJECTIVE

The aim was to better understand how beliefs influence medication adherence in asthma.

METHODS

All participants were prescribed an inhaled corticosteroid for a diagnosis of asthma. Each participant completed a survey consisting of: Beliefs about Medicines Questionnaire (BMQ), Brief-Illness Perception Questionnaire (B-IPQ) and Multi-dimensional Health Locus of Control Scale (MHLCS). Adherence to inhaled corticosteroids was elicited using the Medication Adherence Report Scale (MARS). Multiple linear regression with interaction effects was used to identify significant predictors of medication adherence and interactions between beliefs.

RESULTS

A total of 198 participants completed the survey. The mean(±SD) MARS score was 19.2(±4.5). A multivariable model (adjusted R² = 0.39) predicted adherence using: age, asthma hospitalisation, timeline (B-IPQ) subscale, necessity and concern (BMQ) subscales, doctor (MHLCS) subscale and the two interaction effects (concerns [BMQ] moderated by chance [MHLCS] and treatment control [B-IPQ] moderated by understanding [B-IPQ]).

CONCLUSION

The findings of this study contribute to a better understanding of the role of beliefs in medication adherence in asthma. Certain beliefs meaningfully interrelate and change the relationship they have with medication adherence.

PRACTICE IMPLICATIONS

If these beliefs are causally related to medication adherence and can be intervened upon, the findings are useful for providing targets to personalise adherence support.

Using the extended self-regulatory model to characterise diabetes medication adherence: a cross-sectional study

OBJECTIVES

To cluster the adherence behaviours of patients with type 2 diabetes based on their beliefs in medicines and illness perceptions and examine the psychosocial, clinical and sociodemographic characteristics of patient clusters.

DESIGN

Cross-sectional study.

SETTING

A face-to-face survey was administered to patients at two family medicine clinics in the Midwest, USA.

PARTICIPANTS

One hundred and seventy-four ≥20-year-old, English-speaking adult patients with type 2 diabetes who were prescribed at least one oral diabetes medicine daily were recruited using convenience sampling.

PRIMARY AND SECONDARY OUTCOME MEASURES

Beliefs in medicines and illness perceptions were assessed using the Beliefs about Medicines Questionnaire and the Brief Illness Perception Questionnaire, respectively. Self-reported medication adherence was assessed using the Morisky Medication Adherence Scale. Psychosocial correlates of adherence, health literacy and self-efficacy were measured using the Newest Vital Sign and the Self-efficacy for Appropriate Medication Use, respectively. Two-step cluster analysis was used to classify patients.

RESULTS

Participants' mean age was 58.74 (SD=12.84). The majority were women (57.5%). Four clusters were formed (non-adherent clusters: ambivalent and sceptical; adherent clusters: indifferent and accepting). The ambivalent cluster (n=30, 17.2%) included low-adherent patients with high necessity beliefs, high concern beliefs and high illness perceptions. The sceptical cluster (n=53, 30.5%) included low adherent patients with low necessity beliefs but high concern beliefs and high illness perceptions. Both the accepting (n=40, 23.0%) and indifferent (n=51, 29.3%) clusters were composed of patients with high adherence. Significant differences between the ambivalent, sceptical, accepting and indifferent adherent clusters were based on self-efficacy, illness perception domains (treatment control and coherence) and haemoglobin A1c (p<0.01).

CONCLUSIONS

Patients with diabetes in specific non-adherent and adherent clusters still have distinct beliefs as well as psychosocial characteristics that may help providers target tailored medication adherence interventions.

The association of health literacy with illness perceptions, medication beliefs, and medication adherence among individuals with type 2 diabetes

BACKGROUND

Beliefs in medications and illness perceptions is associated with medication adherence among individuals with diabetes and several adherence interventions focus on patients' beliefs in medicines and illnesses. Though health literacy is important in medication adherence, the relationship between health literacy and medication adherence remains inconclusive; thus raising the question as to whether health literacy has an amplifying or reducing effect on the relationship between beliefs and adherence.

OBJECTIVE

The study examined (1) the association between health literacy, beliefs in medicines, illness perceptions, and medication adherence in individuals with type 2 diabetes and (2) the moderating effects of health literacy (including numeracy and document literacy) on the relationship between illness perceptions, beliefs in medicines, and medication adherence.

METHODS

Adults ≥20 years taking oral diabetes medicines at two family medicine clinics, completed a cross-sectional survey. Participants were assessed on beliefs in medicines, illness perceptions, health literacy, self-efficacy, and medication adherence. Multiple linear regressions examined the effect of health literacy, beliefs and self-efficacy, and the moderator effect of health literacy in the relationship between beliefs and adherence.

RESULTS

Of the 174 participants, more than half were women (57.5%) and white (67.8%). There was a significant positive association between self-efficacy and adherence (β = 0.486, p < .001), and a negative association between threatening illness perceptions and adherence (β = -0.292, p < .001). Health literacy had a significant moderator effect on the relationship between adherence and concerns beliefs (β = -0.156, p = .014) and threatening illness perceptions (β = 0.196, p = .002). The concern beliefs - adherence association was only significant at marginal and adequate literacy levels. When health literacy was separated into numeracy and document literacy, only numeracy moderated the illness perceptions - adherence relationship (β = 0.149, p = .038).

CONCLUSIONS

Health literacy, especially numeracy, needs to be initially addressed before diabetes adherence interventions that address individual concerns about medicines and threatening illness perceptions can work.

In-Home Medication Management Performance Evaluation (HOME-Rx): A Validity Study

OBJECTIVE

This study assessed the initial psychometric properties of a novel in-home, performance-based instrument for older adults called the In-Home Medication Management Performance Evaluation (HOME-Rx).

METHOD

Content validity of the HOME-Rx was determined through the multistep content validity index (CVI) process. Content experts provided qualitative and quantitative judgment of the instrument's ability to measure medication management. The assessment's target population provided qualitative feedback. CVI outcomes informed instrument revisions.

RESULTS

Content experts (n = 7) were in agreement that the overall instrument was valid for measuring medication management (scale-level CVI = .95). Six items were deleted because of low agreement (item-level CVI <.80). Twenty-nine minor edits were made to the order of questions and language. Older adult participants (n = 5) reported the instrument was relevant, acceptable, and easy to understand.

CONCLUSION

The HOME-Rx appears to be a relevant and valid method to assess performance barriers to medication management in the home.

Long-term patterns of adherence to medication therapy among patients with type 2 diabetes mellitus in Denmark: The importance of initiation

AIMS

Poor adherence to medication therapy among type 2 diabetes patients is a clinical challenge. We aimed to determine which factors are associated with the three phases of long-term adherence to medication: initiation, implementation and discontinuation in a register-based study.

METHODS

Adherence to six medicine groups (metformin, sulfonylureas, acetylsalicylic acid, thiazide diuretics, renin angiotensin system inhibitors, and statins) were analysed among 5,232 patients with type 2 diabetes at a tertiary referral hospital during 1998-2009. Rate-ratios of initiation of treatment, recurrent gaps in supply of medication, and discontinuation of treatment were analysed using Poisson regression.

RESULTS

Poor initiation rather than poor implementation or discontinuation was the main contributor to medication nonadherence. Polypharmacy was a risk factor for slower initiation of treatment for all six medicine groups (rate ratio ranging 0.79 95%CI [0.72-0.87] to 0.89 95%CI [0.82-0.96] per already prescribed medicine), but once patients were in treatment, polypharmacy was not associated with recurrence of gaps in supply of medication, and polypharmacy was associated with lower risk of discontinuation (rate ratio ranging 0.93 95%CI [0.86-1.00] to 0.96 95%CI [0.93-0.99] per prescribed medicine). Other identified risk factors for slow initiation, poor implementation, and discontinuation were diabetes duration, younger age, and Turkish/Pakistani origin.

DISCUSSION

This study showed that a risk factor does not necessarily have the same association with all three elements of adherence (initiation, implementation and discontinuation), and that efforts supporting patients introduced to more complex drug combinations should be prioritized.

Clustering medication adherence behavior based on beliefs in medicines and illness perceptions in patients taking asthma maintenance medications

OBJECTIVES

The prevalence of medication non-adherence is 50% in chronic disease conditions and varies from 30% to 70% in asthma maintenance medications. A major drawback in addressing medication non-adherence is the short time available for patient consultations, which limits the ability of the clinician in identifying the problem. Thus, this study explores how medication adherence behavior can be clustered and identifies the unique characteristics of each cluster so that clinicians can recognize the cluster characteristics in patients to provide targeted interventions. The study objectives were to: (1) cluster patients' medication adherence behavior with asthma maintenance medications based on their beliefs in medicines and illness perceptions, and (2) describe the characteristics of the patients in each cluster based on psychosocial, clinical, and demographic characteristics.

RESEARCH DESIGN AND METHODS

A cross-sectional online survey design on a convenience sample of adult individuals who were taking asthma maintenance medications.

MAIN OUTCOME MEASURES

Self-reported medication adherence using Morisky scale, beliefs in medicines using Beliefs in Medicines Questionnaire, and illness perceptions using the Brief Illness Perceptions Questionnaire.

RESULTS

The cluster analysis with 392 subjects resulted in five clusters based on patients' beliefs in medicines and their illness perceptions. The clusters formed had distinct characteristics that lend themselves to monitoring or for which targeted interventions can be framed to improve medication adherence.

LIMITATIONS

The study only examined asthma maintenance medications limiting the generalizability of the study. Also, all the data collected including medication adherence were self-reported data from an online panel. This can cause selection bias and lack of generalizability.

CONCLUSIONS

The study demonstrated how the concept of 'non-adherence' is different for different patients and the need for tailored interventions for each type of non-adherence. With the limited consultation time available for clinicians to communicate with the patients, identifying the characteristics of patients in different clusters can assist clinicians in providing appropriate targeted interventions.