Development and validation of motivational messages to improve prescription medication adherence for patients with chronic health problems
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
References (41)
- et al.
Medication nonadherence is associated with a broad range of adverse outcomes in patients with coronary artery disease
Am Heart J
(2008) Health literacy: a barrier to pharmacist–patient communication and medication adherence
J Am Pharm Assoc
(2009)Applying Weick's model of organizing to health care and health promotion: highlighting the central role of health communication
Patient Educ Couns
(2009)- et al.
A user perspective on type-1 diabetes: sense of illness, search for freedom and the role of the pharmacy
Patient Educ Couns
(2002) - et al.
Medication non-fulfillment rates and reasons for non-fulfillment: narrative systematic review
Clin Ther
(2010) - et al.
Helping patients follow prescribed treatment: clinical applications
J Am Med Assoc
(2002) Adherence to Long-Term Therapies
(2003)- et al.
Adherence to medication
N Engl J Med
(2005) - et al.
Non-adherence to highly active antiretroviral therapy predicts progression to AIDS
AIDS
(2001) Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research
Med Care
(2004)
Medication adherence and associated hemoglobin A1c in type 2 diabetes
Ann Pharmacother
Impact of noncompliance with alendronate and risedronate on the incidence of nonvertebral osteoporotic fractures in elderly women
Br J Clin Pharmacol
Effect of persistent use of antihypertensives on blood pressure goal attainment
Curr Med Res Opin
Nonadherence to antiepileptic drugs and increased mortality: findings from the RANSOM Study
Neurology
Prevalence, predictors, and outcomes of primary nonadherence after acute myocardial infarction
Circulation
Communication, compliance and concordance between physicians and patients with prescribed medications
Am J Publ Health
Systematic review of randomised trials of interventions to assist patients to follow prescriptions for medications
Lancet
Interventions for helping patients to follow prescriptions for medications
Cochrane Database Syst Rev
Interventions to enhance patient adherence to medication prescriptions: scientific review
J Am Med Assoc
Medication adherence physician communication skills
Arch Intern Med
Cited by (39)
Factors influencing poor medication adherence amongst patients with chronic disease in low-and-middle-income countries: A systematic scoping review
2022, HeliyonCitation Excerpt :Refer to Figure 1. The reasons for the exclusion of the 33 articles following full article screening were as follows: nine (9) studies were literature reviews [22, 31, 32, 33, 34, 35, 36, 37, 38]; eighteen (18) studies [39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56] were conducted in high-income countries; two (2) studies [57, 58] presented evidence from both low- and high-income countries and four (4) studies were general reports [59, 60, 61, 62]. The characteristics of the studies included are presented in Table 3 and Table 4.
Management of Rheumatoid Arthritis and the Pharmacist's Role
2019, Encyclopedia of Pharmacy Practice and Clinical Pharmacy: Volumes 1-3Management of rheumatoid arthritis and the pharmacist’s role
2019, Encyclopedia of Pharmacy Practice and Clinical PharmacyDesigning health information programs to promote the health and well-being of vulnerable populations: The benefits of evidence-based strategic health communication
2015, Meeting Health Information Needs Outside of Healthcare: Opportunities and ChallengesImpact of postdischarge statin withdrawal on long-term outcomes in patients with acute myocardial infarction
2015, American Journal of CardiologyCitation Excerpt :It is possible that physicians might prescribe a statin immediately after noticing that a patient has discontinued statin therapy and previous studies did not evaluate the represcription rate or duration of statin discontinuation; therefore, further study is needed to investigate the relation between the duration of statin discontinuation and mortality. Many patient factors, such as education, income, hospital access, cardiac rehabilitation, age, and number of medications before AMI, can affect premature statin discontinuation.8,10,11,16–19 Independent predictors of statin withdrawal in our study were advanced age, development of in-hospital complications, history of stroke, and a higher Killip class.