Development and validation of motivational messages to improve prescription medication adherence for patients with chronic health problems

https://doi.org/10.1016/j.pec.2011.04.029Get rights and content

Abstract

Objective

Poor adherence with prescription medications is a serious problem in health care, especially true for patients with chronic diseases. Previous strategies to promote adherence have generally not resulted in long-term improvements. This research program is designed to improve on past intervention strategies by developing evidence-based and theoretically grounded communication interventions to promote increased adherence.

Methods

Phase 1 of this research program used qualitative methods to examine the uncertainties and concerns that influence medication adherence, identify messages for addressing these concerns, and develop refined motivational messages for promoting medication adherence. Phase 2 of this research program experimentally assessed chronic disease patients’ evaluations of the refined motivational messages.

Results

Phase 1 qualitative research indicated that patient concerns about their need for the prescribed medication (commitment) was the primary adherence issue, followed by concerns about side effects and the safety of prescription medications, and concerns about the medication costs. These three key issues were translated into draft motivational messages which were evaluated, validated, and refined. Phase 2 experimental research showed that exposure to motivational messages increased consumers’ intention to adhere with medication recommendations.

Conclusion

Follow-up intervention research is warranted to test the use of these motivational messages to promote medication adherence.

Practice implications

Pharmacies and pharmacists have the potential to perform a central role in providing consumers with the relevant information they need to make responsible decisions that lead to increased adherence with prescription medication recommendations.

Introduction

Poor adherence to prescription medications is a serious and pervasive problem in the delivery of health care. Approximately 16% of patients fail to fill a new prescription (otherwise known as primary non-adherence or medication non-fulfillment), and one half patients who fill a new prescription stop taking their medications in the first six months therapy (otherwise known as medication non-persistence) [1], [2], [3], [4]. The high rates of medication non-fulfillment and non-persistence transcend time, geography, disease, sociodemographic characteristics, and health care financing and organization. Lack of adherence with medication recommendations limits treatment effectiveness and thwarts the ability of patients to achieve their clinical goals [5], [6], [7], [8], [9], [10], [11], [12]. Concerted strategic efforts must be taken to increase patient adherence with prescribed medication recommendations to improve individual and public health.

Suboptimal patient adherence with prescribed medications is a complex health care problem that is influenced by a range of entrenched patient, provider, health care system, and environmental factors [4], [13]. While no single adherence intervention strategy has been shown to work effectively with all patients, a large body of research suggests that improving patient adherence depends upon establishing a realistic assessment of patients’ knowledge, understanding, and beliefs toward the recommended regimen and engaging in targeted clear, sensitive, and motivating communication with patients to address their perceived impediments to adherence [14], [15], [16], [17], [18].

Community pharmacists are well trained and highly regarded healthcare professionals who are able and willing to implement extended medication services. In the past decade, a range of pharmaceutical care and pharmacy-based disease management programs have been developed and trialed for delivery in primary care settings [19] A recent study of these community pharmacy-based disease management programs targeting adherence in patients with chronic diseases have largely demonstrated positive effects on clinical outcomes other than adherence, but a direct link between the intervention and adherence improvement could not be demonstrated [19]. Thus, it is not known what type of intervention results in the greatest impact and most sustained improvement in medication adherence. Current literature suggests that the effectiveness, appropriateness, and persuasiveness of systemic communication interventions can perform a major role in promoting medication adherence [20], [21], [22], [23], [24]. The research program reported here is designed to build upon past adherence promotion intervention strategies by developing evidence-based and theoretically grounded communication interventions that can be used in disease management programs to promote medication adherence for patients with chronic disease.

Section snippets

Theoretical grounding

Making good decisions about prescribed medications is a complex and highly equivocal health care situation for many patients [25], [26]. Patients often need relevant information to help address uncertainties they may have about prescription medications [15], [21], [22]. Weick's model of organizing provides a useful framework for examining the questions and concerns patients have about their prescription medications [27], [28]. Weick's model describes how cycles of communication can reduce the

Methods

The first phase of this research program examined the uncertainties and concerns that lead patients to not follow medication recommendations about prescription medications, identified message intervention topics for addressing these concerns, and developed, prioritized, and refined motivational messages for promoting medication adherence. In-depth personal interviews were conducted with chronically ill patients who self-reported not adhering to medication recommendations to understand their

Participant characteristics

Seventeen males and 13 females participated in the in-depth interviews, and the average age of the participants was 46 years old. Participants reported having a variety of chronic conditions, including high blood pressure, multiple sclerosis, hypertension, diabetes, depression, HIV, and asthma.

The focus groups were comprised of 28 total participants (11 females, 17 males).

The average age of the focus-group participants was 56 years old. Chronic conditions included heart disease, high blood

Research phase 2: experimental tests of consumer response to messages

The second phase of the research program experimentally tested the refined motivational messages with a large sample of chronically ill patients. While the primary purpose of the phase 2 study was to evaluate the motivational messages, a secondary purpose was to explore whether message framing (positive vs. negative) would influence message evaluation and impact.

Measurement validation

To validate the evaluation measures, we averaged the overall evaluation scores across the three messages for each participant and used this aggregate evaluation measure to predict future adherence intention, attitude, subjective norm, and self-efficacy while controlling for gender, race, age, income, current health status, current adherence status, and current risk levels on commitment, concern, and cost. The results of the regression analyses are summarized in Table 3. The aggregate evaluation

Discussion

The multi-methodological field research program was designed to develop and validate motivational messages and communication intervention strategies to encourage prescription medication adherence among chronically ill patients. Successful attempts to improve patient adherence depend upon establishing realistic assessments of patient knowledge and beliefs toward recommended medication regimens and engaging in targeted motivating communication interventions to address impediments to adherence.

Conflict of interest

There are no conflicts of interest in this research with any of the authors since there is no reference to any specific pharmaceutical products or services in the study.

Acknowledgements

We gratefully acknowledge the support of the members of the Fairfax County Health Literacy Initiative, Harris Interactive, and assorted staff at both the Center for Health and Risk Communication at George Mason University and the US Outcomes Research Division at Merck and Co., Inc.

Role of funding: This research program was funded through a grant from Merck and Co., Inc. There was active collaboration between the Center for Health and Risk Communication at George Mason University and the US

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