Medication adherence is a formidable challenge for the elderly who may have several prescribed medications while dealing with limited incomes and declining health. The primary purpose of this study was to evaluate the Liberty 6000, an automated capsule and tablet dispenser that provides proper medication dosages and is intended to encourage and track medication adherence. Seven focus groups were assembled; these comprised 49 men and women ages 65 to 98 years of Black, Anglo, and Hispanic descent who met the following criteria: living independently or semi-independently, had suffered one or more impairments, and were taking at least three prescription medications. Each focus group session lasted 90 minutes and was tape-recorded and transcribed verbatim, resulting in about 2,600 lines of text. Each question was designed to be open-ended to avoid introducing any bias that might influence the response. The Health Belief Model conceptually guided the study that addressed perceptions of illness susceptibility and severity, barriers, benefits, and cues to action associated with medication adherence. Main benefits of taking medications included avoiding inherited illnesses (or tendencies for illnesses), and reducing illness symptoms. Barriers to taking medications included forgetting, dexterity problems, and high cost. Benefits of the proposed intervention included reminding, caregiver notification, and providing a printed log of medications taken and missed. Barriers associated with the Liberty 6000 included its relatively large size, the difficulties that confronted older adults when loading the device, and its perceived cost. Using an adoption prediction model proposed a way to overcome barriers and encourage acceptance as well as a strategy to maintain acceptance over time. The model also can be used to evaluate a wide variety of medical devices for elderly people. This study identified the advantages and disadvantages of the Liberty 6000. Findings also suggest areas for further investigation by the nursing community and healthcare policy makers in finding solutions to the myriad problems faced by older people in medication adherence.

L’étude du comportement des patients en regard des prescriptions et recommandations qui leur sont faites dans le domaine de la santé est un domaine d’étude qui connaît un essor important. Aujourd’hui, ces comportements se déclinent au sein d’une relation forte entre patients et médecins, ce qu’illustrent par exemple de nombreuses données sur la vaccination. Par ailleurs, l’adhérence joue un rôle majeur à la phase d’évaluation des médicaments, et malgré des investissements importants, elle reste un élément limitant qui peut conduire à rendre difficile l’évaluation de l’efficacité des traitements dans le cadre des essais randomisés. Dans le cas de la grippe, les enjeux de l’étude de ces comportements sont multiples, ils concernent à la fois la vaccination et les traitements antiviraux, à la fois les épidémies de grippe saisonnière et les pandémies dues à des virus émergents. A travers deux études sur l’acceptabilité de la vaccination pandémique et sur l’adhérence au traitement antiviral contre la grippe saisonnière, nous dressons un état des lieux des principaux enjeux liés au suivi des comportements des patients et des médecins. Le travail tente de mettre en évidence l’articulation entre grippe saisonnière et pandémique et nous avons étudié comment les politiques de préparation et de lutte contre la pandémie avaient pu avoir d’importantes conséquences au sein de la communauté scientifique et dans la population. Les résultats publiés apportent un éclairage sur les pratiques des médecins généralistes dans le cadre de la pandémie et sur l’adhérence des patients aux traitements anti-viraux dans le cadre d’un essai clinique randomisé. / In recent years there have been an increased interest in the scientific community for studying how patients conform, or not, to their corresponding prescribed or recommended therapies. Recent data from evaluation of vaccination policy made very clear that those behaviors have to be seen as a component of the strong relation that patients engage with their physician. They are also playing a strong role in the evaluation of treatment efficacy. Indeed the lack of measure and control of adherence to the evaluated intervention,especially in ambulatory medicine, can lead to major bias in the analysis that would give a measure of efficacy. In the context of influenza, those behaviors can have a strong impact on the epidemiology of the disease in a seasonal epidemic context and during pandemics.They concern both the acceptability of vaccination and the adherence to anti-viral therapy. We studied those dimensions through two studies, one survey of general practitioners upon the pandemic vaccinatio, and an analysis of patient adherence to antivirals. Due to its epidemic characteristics, influenza is concerned by global policies, and through those studies we discuss the relationship between those policies and patient’s adherence, and how they make a link between seasonal epidemic and pandemic.

Objective: To perform systematic review of the effects of screening for coronary artery calcium (CAC), a subclinical marker of coronary artery disease (CAD), on behavioral or lifestyle modification, risk perception, and medication adherence. Methods: We searched through CINAHL, PsychInfo, Web of Science, Cochrane Central Register of Control Trials, and PubMed (Medline) for studies on the effects of CAC screening in asymptomatic individuals across three major domains: behavioral modification, risk perception for CAD, and medication adherence. We extracted data from the retrieved studies, assessed and synthesized the information. Results: Of the 15 retrieved studies, three were randomized control trials and 12 were observational studies. CAC score was ascertained either as total score, quartiles, or standardized Agatston's ordinal scale. While all the 15 studies involved issues related to behavioral and medication adherence, four involved risk perception of CAD. Although no standardized approach was used in these studies, CAC screening enhanced medication adherence in 13 of the 15 studies, while the others were mixed. Conclusion: CAC screening improved medication adherence and could likely motivated individuals for beneficial behavioral or lifestyle changes to improve CAD. The mixed results suggest the need for further research because screening for subclinical atherosclerosis has significant implications for early detection and prevention of future cardiovascular events by aggressive risk factors modification.

The overarching goal of this dissertation was to elucidate the psychosocial and behavioral determinants of medication nonadherence among African Americans with hypertension. One in three Americans in the United States has hypertension, and the prevalence of hypertension among African Americans is among the highest in the world. In addition to healthy behaviors such as following a low-salt and low-fat diet, getting regular exercise, and reducing stress, patients with hypertension must also adhere to antihypertensive medications. Poor medication adherence may be driven by psychosocial and behavioral factors; however, the impact of these factors on medication adherence is unclear especially within the African American community. To date, a paucity of research has examined the relationship between psychosocial and behavioral factors such as reported racial discrimination, John Henryism (a measure of active coping and an unhealthy response to stress) and home remedies with medication nonadherence. However, each of these factors has individually been linked with poorer health outcomes among African Americans. Using data from the TRUST study (2006-2008) the association between these constructs and medication adherence was assessed within our sample of 788 African Americans and a comparison group of 137 White participants with hypertension. Ordinal logistic regression was used to assess the association between racial discrimination, John Henryism, home remedies, and medication adherence. The findings from this research indicated more reported racial discrimination, higher John Henryism scores, and greater use of home remedies were associated with lower medication adherence. These findings yield new knowledge about medication adherence and provide practical insights about the psychosocial and behavioral determinants of medication adherence.

Since the Institute of Medicine highlighted the devastating impact of medical errors in their seminal report, “To Err is Human” (2000), efforts have been underway to improve patient safety. A portion of medical errors are due to medication errors, and a large portion of these can be attributed to inadequate laboratory monitoring. In this thesis, I attempt to address this small but important corner of this patient safety endeavor. Why are patients not getting their laboratory monitoring tests? Do they fail to complete them or do doctors not order the tests in the first place? Which prescribers and which patients are least likely to do what is needed for testing to happen and what interventions would be most promising? To address these questions, I conducted a systematic review of existing interventions. I then proceeded with three aims: 1) To identify reasons that patients give for missing monitoring tests; 2) To identify patient and provider factors associated with monitoring test ordering; and 3) To identify patient and provider factors associated with completion of ordered testing. To achieve these aims, I worked with patients and data at the Fallon Clinic. For aim 1, I conducted a qualitative analysis of their reasons for missing tests as well as reporting completion and ordering rates. For aims 2 and 3, I used electronic medical record data and conducted a regression with patient and provider characteristics as covariates to identify factors contributing to test ordering and completion. Interviews revealed that patients had few barriers to completion, with forgetting being the most common reason for missing a test. The quantitative studies showed that: older patients with more interactions with the health care system were more likely to have tests ordered and were more likely to complete them; providers who more frequently prescribe a drug were more likely to order testing for it; and drug-test combinations that were particularly dangerous, indicated by a black box warning, were more likely to have appropriate ordering, though for these combinations, primary care providers were less likely to order tests appropriately, and patients were less likely to complete tests. Taken together, my work can inform future interventions in laboratory monitoring and patient safety.

Les pharmaciens communautaires ont accès en tout temps aux informations concernant les renouvellements d’ordonnance et ont une interaction fréquente avec les patients. Ils sont donc les professionnels de la santé les mieux placés pour intervenir auprès des patients non adhérents à leurs médicaments. Il serait donc pertinent de développer un outil électronique d’aide à la prise en charge des patients non adhérents aux médicaments à usage chronique (e-AdPharm) adapté aux besoins des pharmaciens. Pour ce faire, ce projet a été mené selon un devis mixte. Dans un premier temps, un sondage a été acheminé aux pharmaciens communautaires du Québec afin d’obtenir un portrait global de leur pratique concernant la mesure de l’adhésion et des interventions réalisées auprès des patients pour optimiser l’adhésion. Les résultats du sondage nous indiquent que la méthode la plus utilisée pour identifier les patients non adhérents est le nombre de jours de retard entre les renouvellements, alors que les principales barrières rencontrées pour mesurer l’adhésion sont le manque de temps et le manque d’information sur les ordonnances. La principale intervention réalisée auprès des patients non adhérents est le conseil verbal et les principales barrières pour intervenir sont la réaction négative du patient et le manque de temps. Dans un deuxième temps, quatre groupes de discussion ont été organisés afin de questionner les pharmaciens communautaires sur le développement d’un prototype d’outil électronique pour la prise en charge de l’adhésion. Les pharmaciens souhaitent que l’adhésion soit mesurée sous forme de pourcentage et présentée dans un tableau utilisant un code de couleurs déterminé selon le niveau d’adhésion. Ils ont aussi manifesté un grand intérêt pour l’ajout d’une section permettant le suivi de l’adhésion, incluant un horizon temporel des interventions réalisées et à faire et les causes de la non-adhésion. / Community pharmacists have direct access at all times to prescription refills information and have regular interactions with their patients. Therefore, they are in a unique position to promote optimal medication use. It would therefore be relevant to develop an electronic tool adapted to pharmacists’ needs (e-AdPharm) to provide medication adherence support to patients treated for chronic diseases. This project was conducted according to a mixed study design. First, an invitation to complete a web-based survey was published online through different platforms to describe how community pharmacists in Quebec identify non-adherent patients, monitor medication use, and promote optimal medication adherence. The survey results show that the most common method to identify non-adherent patients was to check gaps between prescription refills whereas the most common barriers to identifying non-adherent patients were lack of time and lack of prescriptions and refills information. The most common intervention to promote adherence was patients’ counselling whereas the most common barriers to intervene were anticipation of a negative reaction from patients and lack of time. Second, four focus groups were organized to design a prototype of an electronic tool adapted to community pharmacists’ needs to provide medication adherence support to patients. Pharmacists wanted a table displaying medication adherence measures for chronic conditions with a color code representing adherence level. They also stressed the importance to have a structured section enabling them to continuously document the interventions made, needs for patients’ follow-ups and non-adherence causes.

The prevalence of hypertension in African Americans is the highest of any population in the United States, and this population also demonstrates lower rates of adherence to mediation. Social support and patient-provider communication have been considered as reinforcing factors to help hypertensive patients achieve optimal blood pressure control. The purpose of this study was to examine the association of social support and patient-provider communication and medication adherence for hypertensive African American men and women. The study was guided by the theory of reasoned action. This study was conducted to determine whether social support and patient-provider communication was associated with medication adherence by self-report, age, and gender. A quantitative cross-sectional design with secondary data analyses was used. The sample included 566 hypertensive African American men and women between the ages of 21and 65 years who participated in a survey administered in the Counseling African Americans to Control Hypertension clinical trial collected between 2004 and 2011. The independent variables were social support and patient-provider communication; the dependent variable was medication adherence. Descriptive, 2-way analysis of variance and hierarchical logistic regression model analyses indicated a significant association between patient-provider communication and medication adherence. There was no significant difference in the relationship between social support, patient-provider communication, and age and gender and medication adherence. The implications of this study for social change include improvement in policies and development programs to support the critical role of providers in ensuring medication adherence in hypertensive African American patients.

Hypertension is defined as an asymptomatic disease which means that the disease is not related to the experience of physical symptoms. This illness is mainly managed by means of oral drug therapies, but research shows that many patients fail to take their medication as they should. Non-compliance is the main problem associated with drug-related treatments, specifically amongst patients diagnosed with chronic conditions, such as hypertension. Past research has focused on many different factors accounting for the high occurrence of non-compliance. Psychological factors relate to patients’ beliefs about their diagnosed illness and their prescribed treatment regimen. These beliefs are conceptualized in terms of the self-regulation model as constituting 5 main dimensions: identity or symptoms of their illness, the consequences of their illness, timeline or specifically referring to the course of the illness (chronic or acute), causes of the illness and controllability. Compliance is vital in the treatment and management of hypertension and research attempting to understand the relation between compliance and patients’ illness cognitions are thus important. The already high prevalence of this condition coupled with an increase in the number of people reporting low compliance suggests the need for intervention. The research question informing the present study was based on the role that psychological factors play in impacting patients’ medication-taking patterns. The medication adherence model describes medication compliance in terms of purposeful action, patterned behaviour and feedback. Purposeful action concerns patients’ intentional decisions to take their medication while patterned behaviour relates to the medication-taking patterns that patients develop. The feedback dimension guides the medication-taking patterns, providing feedback about blood pressure for example. The theory informing the present study involved social cognitive theory, which highlights the role of self-efficacy and outcome expectancies. Self-efficacy is linked with feelings of personal control and specifically refers to people’s belief in their ability to perform certain actions that will produce desired outcomes. Outcome expectancies are described as people’s ability to consider the consequences of their actions and using this information to direct their behaviour. Bearing in mind these two aspects of social cognitive theory, patients’ belief in their ability to conform to their medication instructions together with their expectations that it will improve their health will direct their medication-taking behaviour (i.e. their compliance). The illness-perception questionnaire-revised and the medication-taking questionnaire were used to obtain information about patients’ illness cognitions and their medication compliance. The correlational findings as well as the results produced by regression analysis revealed that, although illness cognitions can play a determining role in patients’ compliance, the present findings found no relation between how patients take their medication and psychological factors, defined in terms of the self-regulation model. Only one of the factors used during factor analysis revealed to significantly predict medication. Limitations associated with the present study might account for this finding and it is recommended that future research should focus on a larger sample and also use supplementary assessment measures in conjunction with self-report measures. Copyright / Dissertation (MA)--University of Pretoria, 2012. / Psychology / unrestricted

<p>This research is based on Construal Level Theory (CLT) and explores the impact of inducing high-level vs low-level construals through various message content on health behavior intentions in the context of medication taking in depression and anxiety. In addition to the direct effects on intentions, the research also explored the mediating roles of perceived psychological distance and risk perception on these intentions and the moderating effects of age and mental health stigma.</p><p>Previous work in CLT suggests that concrete low-level construals, or mental representations, are likely to dominate thinking near decision times, but those who remain focused on more abstract high-level construals are more likely to follow through with good intentions and that a person can be induced to focus on these abstract benefits and goals through messaging. However, evidence that a person’s construal level mindset can be maintained over time to support ongoing intended behavior in the face of daily cognitive demands is lacking.</p><p>Messages were sent via secure text service to a mobile device twice weekly for 4-weeks. Results of within and between-subjects analysis showed that low-level construal messages have the greatest direct effect on behavioral intentions (BI) (<i>Wilks’ λ F</i>=11.591, <i>p</i><.001, <i>η</i>^<em>2</em>=.056) and actual medication taking behavior (<i>Wilks’ λ</i> <i>F</i>=2.979, <i>p</i>=.051, <i>η</i>^<em>2</em>=.271) as compared to controls. Significant changes were also seen in perceived social distance to a future risk (SD) (<i>Wilks’ λ F</i>=61.654, <i>p</i><.001, <i>η</i>^<em>2</em>=.240) and overall risk perception (RP) (<i>Wilks’ λ</i> <i>F</i>=3.393, <i>p</i>=.019, <i>η</i>^<em>2</em>=.058) over the 4-week study vs controls, but no mediation effect was detected between messaging, SD, or RP and BI. Finally, mental health stigma (MHS) was seen to moderate the direct effect of the messaging on BI (<i>F</i>=2.701, <i>p</i>=.048, <i>R</i>^<em>2</em><i>chng</i>=.043).</p><p>Results suggest text messages delivered over time can positively impact treatment adherence intention, behavior, and health attitudes in patients with depression and anxiety. In addition, the construal level focus of the messages is likely to impact those outcomes differentially in various patient groups.</p>

In order for a medication treatment to be considered successful, several roles and functions along the pharmacological treatment chain must function and cooperate effectively. The chain can most easily be described as five transitions; diagnosis, prescription treatment, dispensing, drug use and finally results and follow-up. Unfortunately, there are many problems and inefficiencies in the pharmacological drug chain. Unfortunately, those who study medication errors and their solutions have focused on individual parts of the pharmacological treatment system. However, for this reason, this study aims to develop a general framework for system analysis of inefficiencies along the pharmacological treatment chain. Due to the size of the problem, this project focused on medication adherence. Adherence can be defined as to what extent the patient follows the medication treatment plan. Adherence has many known problems and difficulties, among other things, it has major financial consequences. It can also be difficult to measure compliance, and there is no recognized perfect method. A system dynamic model is a theoretical image of a real system or object, which is a model used to understand the nonlinear behavior of complex systems. These models are useful when considering interventions and their effects when there are complex relationships. The project started with a literature study, and then went into data collection. Here, a search design and refinements were designed to find relevant articles. Once the articles were selected, the data was compiled from the articles and the analysis began. Here, factors and effects on adherence were identified as well as other interesting information from the articles. When the information was compiled and analyzed, the system dynamic model was created. The model was then sent via email to experts in the field to validation and revise the model. During the data collection, 23 relevant articles were found, compiled into 38 factors associated with compliance. In addition to these factors, 8 were excluded because they were too disease-specific or too ambiguous in their effect of adherence. The various articles studied many different chronic diseases, but hypertension was the most common. How adherence was measured in the articles also varied greatly, however, some form of self-report or questionnaire was most common method used. Three out of seven experts responded to the sent-out model and provided valuable comments. Although these are not sufficient to validate the model, their views showed that a validation can be designed in this way. The model would have to be sent to a larger set of experts and stakeholders, but because these experts are recognized in their fields, it gave weight to the results even though they were few reviewers. With the support of the literature and the experts’ statement, it was concluded that this model provides a good foundation and structure to continue to build upon. In addition, the model has proven to have many key relationships and cornerstones with important and relevant factors. It is also concluded that it is possible to translate the model into quantitative patterns, which is based on the fact that the factor itself can be translated quantitatively. Overall, it is also finally concluded that the model created in this project could be of great use in future projects when working towards a framework for system analysis of inefficiencies along the pharmacological treatment chain.