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Agradecemos a compreensão. on 2016-10-21T16:11:25Z (GMT) / Submitted by LAYLA TATIANE CÔCO null (laylacocco@hotmail.com) on 2016-10-21T20:17:21Z No. of bitstreams: 1 Layla Tatiane Côco.pdf: 1468670 bytes, checksum: ed5a5bd85ada5153e066b525696a98e1 (MD5) / Approved for entry into archive by Juliano Benedito Ferreira (julianoferreira@reitoria.unesp.br) on 2016-10-24T20:07:56Z (GMT) No. of bitstreams: 1 coco_lt_me_bot.pdf: 1468670 bytes, checksum: ed5a5bd85ada5153e066b525696a98e1 (MD5) / Made available in DSpace on 2016-10-24T20:07:56Z (GMT). No. of bitstreams: 1 coco_lt_me_bot.pdf: 1468670 bytes, checksum: ed5a5bd85ada5153e066b525696a98e1 (MD5) Previous issue date: 2016-09-06 / Introdução: Adesão ao tratamento refere-se a um comportamento ativo do paciente em relação à doença e ao tratamento compartilhando as decisões com o profissional de saúde. Considera-se a adesão um fenômeno resultante da interação de fatores de diferentes naturezas que afetam diretamente o comportamento do paciente: fatores relacionados ao indivíduo; fatores sociais, econômicos; fatores relacionados ao serviço de saúde e aos profissionais de saúde e ainda os fatores relacionados à doença e ao tratamento. Objetivo: Este estudo propõe-se a realizar uma revisão integrativa da literatura nacional e internacional sobre fatores associados à adesão ao tratamento da Hepatite C, com especial ênfase aos fatores psicológicos e sociais. Método: Foram estabelecidas as várias fases deste estudo, segundo o procedimento proposto: elaboração da pergunta de pesquisa, estabelecimento dos critérios para seleção da amostra, apresentação das características das pesquisas selecionadas, análise dos dados, interpretação dos resultados e a síntese da revisão. Realizou-se busca dos artigos nas bases de dados: Medline, Web of Science, Cinahl, Lilacs, Psycinfo, Scopus e Scielo. Foram incluídos artigos nos idiomas português, inglês e espanhol, publicados entre os anos 2000 a 2016 e excluídos os artigos que não foram considerados pertinentes ao objeto de estudo. Resultados: Obteve-se um corpus com 14 artigos, totalmente estrangeiro, publicado em inglês, nos anos de 2001 a 2015, majoritariamente indexados no Medline, o método quantitativo predominou entre as pesquisas selecionadas (onze artigos) em relação aos qualitativos (três artigos). As variáveis psicológicas pesquisadas em relação à possível associação com a adesão/não adesão ao tratamento de Hepatite C, nos estudos quantitativos, foram: presença de sintomas psicológicos, como ansiedade e depressão, raiva, hostilidade, transtornos psiquiátricos, autoeficácia, ainda foram investigados funcionamento social, problemas interpessoais e comportamentos relacionados à saúde. Esses estudos avaliaram também a possível influência na adesão ao tratamento de características sociodemográficas: idade, ocupação, escolaridade, sexo, etnia, apoio social e ainda o uso de álcool e outras drogas (abstinência e tratamento). Entre estes fatores foi verificada associação significativa entre não adesão e presença de transtornos psiquiátricos, sintomas de depressão, ansiedade fóbica, comportamento hostil, intrusividade, uso regular de substâncias, idade (ser mais jovem), desemprego, não estar em relacionamento estável. Já as variáveis associadas estatisticamente com adesão ao tratamento foram iniciar medicação psiquiátrica durante o tratamento, comportamentos relacionados à saúde (dieta e comportamento alimentar), menor distância do centro de tratamento, genótipo 3, coinfectado HIV e virgens de tratamento. Também foram avaliados três estudos qualitativos em que foram apontadas e discutidas como barreiras e como facilitadores da adesão ao tratamento: percepção e experiências com o tratamento, presença de estigma, apoio social, estratégias de enfrentamento, sistemas de crenças, medo e ansiedade. Conclusões: Conhecer os fatores que podem interferir na adesão ao tratamento da Hepatite C é extremamente importante, seja pela gravidade da doença, pelo aumento de sua incidência, pela complexidade e custo do tratamento que exige adesão completa para se obter RVS, além do impacto pessoal e social dessa doença e de seu tratamento, que faz da Hepatite C um problema de saúde pública. Considera-se que a relevância desta revisão está ainda em apontar a necessidade de se ampliarem as pesquisas sobre o papel das variáveis psicológicas e sociais sobre as características da comunicação com os profissionais de saúde que possam favorecer melhor adesão. Pesquisas com esse intuito, ainda tão ausentes na literatura, poderão contribuir para o desenvolvimento de programas psicoeducativos para que se amplie a adesão aos tratamentos hoje disponíveis. / Introduction: Adherence to treatment refers to an active patient behavior regarding the disease and treatment by sharing decisions with the health professional. Adherence is considered a phenomenon resulting from the interaction of factors of different nature that directly affect patient behavior: factors related to the individual; social and economic factors; factors related to health care and health care professionals and also factors related to the disease and treatment. Objective: This study aims to carry out an integrative review of national and international literature of factors associated with adherence to treatment of hepatitis C, with special emphasis to psychological and social factors. Method: We establish the various stages of this study according to the proposed procedure: the development of the research question, establishment of criteria for sample selection, presentation of the characteristics of the selected research, data analysis, interpretation of results and a summary of the review. A search of articles was conducted in the following databases: Medline, Web of Science, CINAHL, Lilacs, Psycinfo, Scopus and Scielo. Complete articles were included, in Portuguese, English and Spanish, published between 2000 and 2016, and articles considered not relevant to the object of study were excluded. Results: Obtained a corpus with 14 totally foreign articles published in English between 2001-2015, mainly indexed in Medline, the quantitative method predominated among the selected studies (eleven articles) against three articles using the qualitative method. The psychological variables studied in relation to the possible association with adherence/non-adherence to treatment of hepatitis C, in the quantitative study were: presence of psychological symptoms such as anxiety and depression, anger, hostility, psychiatric disorders, and self-efficacy, but social functioning, interpersonal problems, behaviors related to health and quality of life were also investigated. These studies also assessed the possible impact on treatment adherence of sociodemographic characteristics: age, occupation, education, gender, ethnicity, social support and even the use of alcohol and other drugs (abstinence and treatment). Among these factors there was significant association between non-adherence and presence of psychiatric disorders, symptoms of depression, phobic anxiety, hostile behavior, intrusiveness, regular substance use, age (being younger), unemployment, not being in a stable relationship. The variables statistically associated with adherence to treatment were: starting psychiatric medication during treatment, health-related behaviors (diet and eating behavior), shorter distance from the center of treatment, genotype 3, HIV co-infected and treatment first timers. The three qualitative studies were also evaluated and the barriers and facilitators of adherence to treatment were identified and discussed: perception and experiences with treatment, presence of stigma, social support, coping strategies, belief systems, fear and anxiety. Conclusions: Knowing the factors that can interfere with adherence to hepatitis C treatment is extremely important because the severity of the disease, the increase in incidence, the complexity and cost of treatment that requires full adherence to achieve SVR in addition to the personal and social impact of the disease and its treatment, which makes it a public health problem. It is considered that the relevance of this review is still to point out the need to expand research on the role of psychological and social variables on the characteristics of communication with health professionals who can promote better adherence. Research to this end, yet so absent from the literature, may contribute to the development of psychoeducational programs to broaden adherence to currently available treatments.

Class of 2016 Abstract / Objectives: Patient medication adherence is a basic requirement for treating chronic myelogenous leukemia (CML) with oral tyrosine kinase inhibitors (TKIs). When imatinib adherence rates are less than 80 or 90 percent, major and complete molecular responses, respectively, do not happen. The purpose of this study was to determine the effect of a real-time medication monitoring (RTMM) reminder system adherence program on the medication possession ratio (MPR). Methods: This analytic study was a retrospective cohort study and used data extracted from chart reviews for patients who received services from 2011 to 2015. It was approved by the Institutional Review Board. The study consisted of an intervention group and a control group (50 patients each). MPRs, demographic, descriptive, and categorical variables were summarized using means, standard deviations (SD), and frequencies/percentages. Results: The study population consisted of adult patients (mean age=62.2, SD=2.7, 50% male) treated by Avella Specialty Pharmacy who received imatinib or nilotinib as treatment for CML, gastrointestinal stromal tumors (GIST), or a similar positive Philadelphia chromosome cancer. Only 4% of patients in the intervention group had an < 85% MPR, compared to 46% in the control group (p < 0.001). Conclusions: In those patients who had an MPR of ≥ 85%, the difference between the groups was statistically significant. As past studies have shown, adherence rates greater than 90% have a higher likelihood of a major or complete molecular response and a greatly reduced risk of disease progression.

A hipertensão (HAS) é um problema de saúde pública global que afeta, em média, um quarto da população mundial, desencadeando elevados gastos de saúde e um número elevado de mortes, anualmente. A falta de adesão ao tratamento para a HAS é a principal responsável pelo aumento da morbimortalidade, das internações hospitalares, dos gastos em saúde e pior qualidade de vida entre os pacientes. Objetivo: Analisar os fatores clínicos, demográficos e socioeconômicos associados ao grau de adesão de adultos e idosos hipertensos, ao tratamento para HAS no Brasil, descrevendo seu grau de adesão. Metodologia: Trata-se de um estudo analítico de corte transversal, utilizando dados secundários da Pesquisa Nacional de Saúde (PNS) realizada pelo IBGE em 2013, envolvendo 7203 pacientes hipertensos, adultos e idosos de ambos os sexos, que buscou analisar os fatores associados ao grau de adesão ao tratamento para hipertensão, por meio de regressão beta com função de ligação logit. A análise das variáveis estatisticamente significativas, deu-se por meio da razão de chances e probabilidade de associação com o grau de adesão. Resultados: O grau de adesão médio da amostra estudada foi de 69,48%. Os fatores encontrados associados ao grau de adesão foram: a presença de outras doenças além da hipertensão, o grau de depressão, a avaliação do estado de saúde, a região do país, o gênero, a idade, a etnia, viver ou não com companheiro e a escolaridade, sendo que, ser do gênero feminino foi o fator que mais favoreceu a adesão e possuir um grau de depressão severo, o que menor favoreceu à adesão. Conclusão: Tanto fatores clínicos, socioeconômicos, quanto demográficos foram significativamente associados ao grau de adesão ao tratamento da HAS. Sugere-se que estudos relacionados à melhora da adesão em relação a cada um dos fatores analisados sejam realizados, de forma a amenizar os efeitos deletérios ou potencializar seus efeitos benéficos, principalmente quanto a indivíduos do gênero masculino, que apresentam maior tendência de não adesão aos tratamentos de saúde de forma geral. / Hypertension is a global public health problem that affects on average one quarter of the world population, triggering high health spending and a high number of deaths annually. The lack of adherence to treatment for hypertension is mainly responsible for the increased morbidity and mortality, hospital admissions, spending on health and lower quality of life among patients. Objective: To analyze the clinical, demographic and economic partner associated with the degree of adherence of adults and elderly hypertensive patients, treatment for hypertension in Brazil, describing their degree of adherence. Methodology: This is an analytical cross-sectional study, using secondary data from the National Health Survey (PNS) held by IBGE in 2013, involving 7203 hypertensive patients, adults and seniors of both genders, who sought to relate the factors associated with the degree of adherence to treatment for hypertension, through beta regression with logit link function. The analysis of statistically significant variables, occurred through the odds ratio and likelihood of association with the degree of compliance. Results: The mean adherence degree of the sample was 69.48%. The factors found associated with the adherence degree were: the presence of other diseases besides high blood pressure, the degree of depression, assessment of health status, region of the country, gender, age, ethnicity, living or not living with a partner and education, and that being female is the main factor that favors adhesion and have a degree of severe depression, which favors smaller accession. Conclusion: Both clinical, economics, and demographics were significantly associated with the degree of adherence to treatment of hypertension. It is suggested that studies related to the improvement of adherence for each of the analyzed factors are carried out in order to mitigate the deleterious effects or enhance their beneficial effects, especially as for male individuals, who are more likely not to adhere to health treatments in general.

A hipertensão (HAS) é um problema de saúde pública global que afeta, em média, um quarto da população mundial, desencadeando elevados gastos de saúde e um número elevado de mortes, anualmente. A falta de adesão ao tratamento para a HAS é a principal responsável pelo aumento da morbimortalidade, das internações hospitalares, dos gastos em saúde e pior qualidade de vida entre os pacientes. Objetivo: Analisar os fatores clínicos, demográficos e socioeconômicos associados ao grau de adesão de adultos e idosos hipertensos, ao tratamento para HAS no Brasil, descrevendo seu grau de adesão. Metodologia: Trata-se de um estudo analítico de corte transversal, utilizando dados secundários da Pesquisa Nacional de Saúde (PNS) realizada pelo IBGE em 2013, envolvendo 7203 pacientes hipertensos, adultos e idosos de ambos os sexos, que buscou analisar os fatores associados ao grau de adesão ao tratamento para hipertensão, por meio de regressão beta com função de ligação logit. A análise das variáveis estatisticamente significativas, deu-se por meio da razão de chances e probabilidade de associação com o grau de adesão. Resultados: O grau de adesão médio da amostra estudada foi de 69,48%. Os fatores encontrados associados ao grau de adesão foram: a presença de outras doenças além da hipertensão, o grau de depressão, a avaliação do estado de saúde, a região do país, o gênero, a idade, a etnia, viver ou não com companheiro e a escolaridade, sendo que, ser do gênero feminino foi o fator que mais favoreceu a adesão e possuir um grau de depressão severo, o que menor favoreceu à adesão. Conclusão: Tanto fatores clínicos, socioeconômicos, quanto demográficos foram significativamente associados ao grau de adesão ao tratamento da HAS. Sugere-se que estudos relacionados à melhora da adesão em relação a cada um dos fatores analisados sejam realizados, de forma a amenizar os efeitos deletérios ou potencializar seus efeitos benéficos, principalmente quanto a indivíduos do gênero masculino, que apresentam maior tendência de não adesão aos tratamentos de saúde de forma geral. / Hypertension is a global public health problem that affects on average one quarter of the world population, triggering high health spending and a high number of deaths annually. The lack of adherence to treatment for hypertension is mainly responsible for the increased morbidity and mortality, hospital admissions, spending on health and lower quality of life among patients. Objective: To analyze the clinical, demographic and economic partner associated with the degree of adherence of adults and elderly hypertensive patients, treatment for hypertension in Brazil, describing their degree of adherence. Methodology: This is an analytical cross-sectional study, using secondary data from the National Health Survey (PNS) held by IBGE in 2013, involving 7203 hypertensive patients, adults and seniors of both genders, who sought to relate the factors associated with the degree of adherence to treatment for hypertension, through beta regression with logit link function. The analysis of statistically significant variables, occurred through the odds ratio and likelihood of association with the degree of compliance. Results: The mean adherence degree of the sample was 69.48%. The factors found associated with the adherence degree were: the presence of other diseases besides high blood pressure, the degree of depression, assessment of health status, region of the country, gender, age, ethnicity, living or not living with a partner and education, and that being female is the main factor that favors adhesion and have a degree of severe depression, which favors smaller accession. Conclusion: Both clinical, economics, and demographics were significantly associated with the degree of adherence to treatment of hypertension. It is suggested that studies related to the improvement of adherence for each of the analyzed factors are carried out in order to mitigate the deleterious effects or enhance their beneficial effects, especially as for male individuals, who are more likely not to adhere to health treatments in general.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-06-30T11:38:09Z No. of bitstreams: 1 elisadeoliveiramarsicano.pdf: 1820352 bytes, checksum: fc21554f216954440f19500eb4bf4483 (MD5) / Approved for entry into archive by Diamantino Mayra (mayra.diamantino@ufjf.edu.br) on 2016-07-05T16:33:03Z (GMT) No. of bitstreams: 1 elisadeoliveiramarsicano.pdf: 1820352 bytes, checksum: fc21554f216954440f19500eb4bf4483 (MD5) / Made available in DSpace on 2016-07-05T16:33:03Z (GMT). No. of bitstreams: 1 elisadeoliveiramarsicano.pdf: 1820352 bytes, checksum: fc21554f216954440f19500eb4bf4483 (MD5) Previous issue date: 2012-08-31 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / A Doença Renal Crônica (DRC) constitui hoje um importante problema médico e de saúde pública. O transplante renal é, atualmente, a melhor opção terapêutica para o paciente com DRC, tanto do ponto de vista médico, quanto social ou econômico. Para proporcionar maior segurança terapêutica e controle de complicações clínicas e cirúrgicas existem estratégias que são fundamentais. Uma questão considerada relevante é a não aderência (NA) ao uso das medicações e ao tratamento proposto. A aderência é definida como o grau de concordância entre o comportamento de um paciente em relação às orientações do médico e/ou de outro profissional da saúde. É um fenômeno multidimensional que envolve fatores determinados por questões socioeconômicas, pelo sistema de saúde, pelos profissionais de saúde, por fatores relacionados à terapia e ao paciente. Para o diagnóstico da NA podemos utilizar métodos diretos e indiretos. Este estudo teve como objetivos adaptar e validar para a população de transplantados brasileiros o instrumento The Basel AssessmentofAdherencewithImunossupressiveMedicationScale (BAASIS), utilizando uma amostra de transplantados renais atendidos no ambulatório do Núcleo Interdisciplinar de Estudos e Pesquisas em Nefrologia da Universidade Federal de Juiz de Fora (Niepen), determinar a frequência de NA na população estudada, avaliada através do emprego três métodos diagnósticos e avaliar a associação entre os fatores de risco e a presença de NA. Trata-se de um estudo transversal onde foram analisados 100 pacientes transplantados renais com mais de um ano de transplante em acompanhamento ambulatorial no Niepen. A adaptação cultural foi realizada utilizando o protocolo de Guillemin (i.e. tradução, retrotradução, análise por comitê de especialistas e pré-teste). Para verificação das propriedades psicométricas foram aplicados os testes de reprodutibilidadeintra e interobservador, alfa de Cronbach, correlação do BAASIS com a Medida de Aderência ao Tratamento – MAT e análise fatorial. Além de análise univariada e multivariada para os fatores associados a NA. Os pacientes foram classificados em dois grupos: aderentes e não aderentes através da utilização de três métodos diagnósticos (BAASIS, opinião dos profissionais e nível sangúineo dos imunossupressores) e as condições associadas aNA foram coletadas através de um questionário e do prontuário. A média de idade dos pacientes foi de 45±13,5 anos, 65% eram homens e 89% receberam o enxerto de um doador vivo. O instrumento BAASIS foi adaptado transculturalmente para língua portuguesa sem dificuldades. Em relação às propriedades psicométricas, encontramos baixa variância, de 0,007 e 0,003 nos testes de reprodutibilidade intra e interobservador; a correlação com o MAT foi de 0,65; cargas fatoriais aceitáveisdas três primeiras questões do BAASIS (r=0,76; r=0,80, and r=0,68), e alfa de Cronbach de 0,7. 51% dos pacientes foram considerados não aderentes utilizando-se três métodos para avaliar a aderência ao tratamento imunossupressor. As variáveis relacionadas com a NA foram: residir a mais de 100 km do centro transplantador (54,9 vs. 38,8%, p<0,07), renda familiar maior que 5 salários mínimos (21,6 vs. 4%, p<0,009), e ter acesso a exames por seguro de saúde (35,3% vs. 18,4%,p<0,01). No modelo de regressão logística apenas renda familiar maior que cinco salários foi fator de risco para NA (OR 5,0 IC:1,01 - 25,14; p<0,04). Os resultados demonstraram que a BAASIS apresenta boas propriedades psicométricas, e este estudo viabliza o seu uso na prática clínica e em pesquisas sobre aderência em TxR. Nesta amostra, as variáveis associadas com a NA foram relacionadas às condições socioeconômicas: morar distante do centro transplantador, melhor renda familiar e ter acesso a exames por seguro de saúde. Ressaltamos que este é o primeiro estudo brasileiro com metodologia adequada sobre fatores de risco e frequência de NA no pós TxR. / Chronic Kidney Disease (CKD) is now an important medical and public health problem. Kidney transplantation is currently the best therapeutic option for patients with CKD, both from the medical, the social or economic´s points of view. To promote safety and therapeutic control of clinical and surgical complications, some strategies are fundamental. An issue that is considered very important is nonadherence (NA) to the use of medications and the proposed treatment. Adherence is defined as the degree of agreement between the behavior of a patient in relation to the advice of the physician and/or other healthcare professional. It is a multidimensional phenomenon that involves factors determined by socio-economic issues, the health system, health professionals, factors related to therapy and to the patient. For the diagnosis of NA we can apply direct and indirect methods. This study aimed to validate to the Brazilian transplant population the instrument “The Basel Assessment of Medication Adherence with Imunossupressive Scale” (BAASIS), using a sample of renal transplant patients, form the outpatient clinic of the NúcleoInterdisciplinar de Estudos e PesquisasemNefrologia da Universidade Federal de Juiz de Fora (Niepen),to assess the frequencyof NAin the studied population, evaluatedby employingthree diagnostic methodsand to evaluate theassociation betweenrisk factorsand the presence ofNA. This is a cross-sectional study of 100 renal transplant recipients with more than one year of transplant, followed as an outpatient at Niepen. The BAASIS (English version) was transculturally adapted and psychometric properties were assessed. Transcultural adaptation was performed using the Guillemin protocol (i.e. translation, back translation, analysis by an expert committee, and pre-testing). Psychometric testing included intra and inter observer reproducibility,Cronbach’salpha,correlation between BAASIS and Measure of Adherence to Treatment and factorial analysis. In alsounivariate and multivariate analyzes for factors associated with NA. Patients were classified into two groups: adherent and non-adherent using three diagnostic methods (The BAASIS, the professionals' opinion and imunossupressivesblood levels) and the conditions associated with NA were collected from a questionnaire and medical files. The mean age of patients was 45 ± 13.5 years, 65% were men and 89% received a graft from a living donor. On testing the psychometric properties of reliability, intra-observer reproducibility showed a variance of 0.007, with inter-observer reproducibility having a variance of 0.003, suggesting preciseness was achieved. For Validity, in construct validity, exploratory factorial analysis demonstrated unidimensionality of the first three questions (r=0.76; r=0.80, and r=0.68). For criterion validity, the adapted BAASIS was correlated with another self-reporting instrument – Measure of Adherence to Treatment (MAT) and showed good congruence/correlation (r=0.65). Cronbach's alpha was0.7. 51% of patients were considered nonadherente using three methods to assess adherence to immunosuppressive treatment. Variables related to NA were: living more than 100 km from the transplant center (54.9 vs. 38.8%, p<0.07), family income higher than five minimum wages (21.6 vs. 4%, p<0.009), and access to lab tests from health insurance (35.3% vs. 18.4%, p<0.01). In the logistic regression model only low family income higher than five minimum wages was a risk factor for NA (OR 5.0 CI: 1.01 to 25.14, p<0.04). The results showed the BAASIS has good psychrometric properties and this study enables its use in clinical practice and in researches on adherence in kidney transplant. In this sample, the variables associated with NA were related to socioeconomic conditions: living far from the transplant center, better income and having access to private health insurance. We emphasize that this is the first Brazilian study, with appropriate methodology, on risk factors and frequency of NA post kidney transplantation.

Les traitements en cancérologie sont soumis au même risque de non-adhérence que les autres traitements ambulatoires au long cours. Ce travail de thèse a pour objectifs : i) d'étudier les facteurs de risque de dis-adhérence ; ii) de développer un programme d'éducation du patient (PEP) permettant d'améliorer l'adhérence des patients. La première étude étudie les facteurs de risque de non adhésion liés à l'interaction avec le système de soin ; les pratiques des oncologues français relatives à la prescription, la surveillance et l'accompagnement des patients ne sont pas suffisantes actuellement pour assurer un bon niveau de sécurité et d'adhérence des patients sous anticancéreux oraux. Les facteurs de risque de non adhésion liés au patient et au traitement sont étudiés dans la deuxième étude, chez des patients traités par capécitabine pour cancer du sein ou du côlon. Les patients actifs avec un niveau éducatif élevé seraient moins adhérents que les 2 autres. L'ensemble des patients sous capécitabine ont des comportements de sur-adhérence qui mettent en péril leur vie à cause des toxicités induites. La troisième étude présente l'évaluation d'un PEP construit selon une méthodologie standardisée. Ce programme démontre une efficacité dans l'amélioration des connaissances des patientes et de la confiance dans le traitement. Cette étude pilote a permis de modifier ce programme pour qu'il soit plus efficace. Identifier les facteurs de risque de non adhérence aux traitements anticancéreux oraux, à l'aide de méthodologies valides et adaptées au contexte, permet de construire des stratégies d'amélioration de l'adhérence ciblées et efficaces, en faisant levier sur ces facteurs / Non-adherence to oral chemotherapies can lead to lowered efficacy and increased risk of adverse events. The objective of this PhD work was twofold : i) to identify dis-adherence risk factors ii) to develop and test the feasibility of a validated, tailored therapeutic educational program with the aim of improving adherence to oral endocrine adjuvant chemotherapy in breast cancer. A survey was carried out to collect information on drug prescription, administration and surveillance, in order to identify non- adherence risk factors related to health professional behaviors : the majority of prescribers followed no standards in prescription writing, safety monitoring, toxicity prevention and patient education. A cohort study was carried out to identify adherence profiles among patients treated with capecitabine, using a mixed method. A profile of low adherence appeared (highly educated patients, with an irregular active life, with occupied relatives) and absolutely all patients showed an over-adherence profile (with a high risk of toxicity). The pilot study assessing the development and the feasibility of an educational program tailored to patients’ needs led to the improvement of the program : an extra session dealing with anxiety was built, and a new recruitment method was developed. Otherwise, the program succeeded in improving knowledge and trust in the treatment. This PhD work succeeded in identifying new dis-adherence risk factors, thanks to qualitative-quantitative methods. Those risk factors were incorporate in the development process of an educational program, in order to tailor it to the targeted population. This method should guarantee the efficacy of the program on patient’s adherence

Background: Improved clinical effectiveness and therefore positive modification of multiple sclerosis (MS) with basic therapy can be achieved by long-term regular intake of drugs as prescribed but investigations have shown that a high percentage of patients do not take their medications as prescribed. Objectives: We assessed the satisfaction and adherence of patients with MS with their current disease-modifying treatment under clinical practice conditions. We compared different facets of satisfaction as well as their internal relationship and identified predictors in an exploratory manner. Methods: Therapy satisfaction in patients with relapsing–remitting multiple sclerosis (THEPAMS) was a noninterventional, prospective cross-sectional study performed throughout Germany in 2013 and 2014, and included patients with clinically isolated syndrome or relapsing–remitting MS. We applied a standardized approach to document satisfaction and adherence by patient-reported outcomes (Treatment Satisfaction Questionnaire for Medication) as well as by physician ratings. Results: Of 3312 patients with a mean age of 43.7 years, 73.3% were women and the mean level of disability according to the Expanded Disability Status Scale was 2.29; 13.3% did not receive any medication at the time of documentation, 21.3% received interferon β1a intramuscularly, 20.7% had interferon β1a subcutaneously, 17.0% had interferon β1b subcutaneously and 23.7% had glatiramer acetate. Adherence rates varied between 60% (lifetime) and 96.5% (current medication). Differences between current medications were found for side effects and convenience scores but not for effectiveness, satisfaction and adherence. Higher global satisfaction and effectiveness were associated with fewer relapses, longer duration of medication, lower disability score and the absence of several side effects. Conclusion: In a connected model of patient satisfaction, effectiveness, side effects, convenience and adherence, patients’ individual needs and concerns have to be addressed. Most differences were found with respect to side effects and convenience of treatment. Therefore, an improvement in these two domains seems to be the most promising proximate approach to elevate adherence levels.

Objectif principal: Il n’est pas démontré que les interventions visant à maîtriser voire modérer la médicamentation de patients atteints d’hypertension peuvent améliorer leur gestion de la maladie. Cette revue systématique propose d’évaluer les programmes de gestion contrôlée de la médicamentation pour l’hypertension, en s’appuyant sur la mesure de l’observance des traitements par les patients (CMGM). Design: Revue systématique. Sources de données: MEDLINE, EMBASE, CENTRAL, résumés de conférences internationales sur l’hypertension et bibliographies des articles pertinents. Méthodes: Des essais contrôlés randomisés (ECR) et des études observationnelles (EO) ont été évalués par 2 réviseurs indépendants. L’évaluation de la qualité (de ce matériel) a été réalisée avec l’aide de l’outil de Cochrane de mesure du risque de biais, et a été estimée selon une échelle à quatre niveaux de qualité Une synthèse narrative des données a été effectuée en raison de l'hétérogénéité importante des études. Résultats: 13 études (8 ECR, 5 EO) de 2150 patients hypertendus ont été prises en compte. Parmi elles, 5 études de CMGM avec l’utilisation de dispositifs électroniques comme seule intervention ont relevé une diminution de la tension artérielle (TA), qui pourrait cependant être expliquée par les biais de mesure. L’amélioration à court terme de la TA sous CMGM dans les interventions complexes a été révélée dans 4 études à qualité faible ou modérée. Dans 4 autres études sur les soins intégrés de qualité supérieure, il n'a pas été possible de distinguer l'impact de la composante CMGM, celle-ci pouvant être compromise par des traitements médicamenteux. L’ensemble des études semble par ailleurs montrer qu’un feed-back régulier au médecin traitant peut être un élément essentiel d’efficacité des traitements CMGM, et peut être facilement assuré par une infirmière ou un pharmacien, grâce à des outils de communication appropriés. Conclusions: Aucune preuve convaincante de l'efficacité des traitements CMGM comme technologie de la santé n’a été établie en raison de designs non-optimaux des études identifiées et des ualités méthodologiques insatisfaisantes de celles-ci. Les recherches futures devraient : suivre les normes de qualité approuvées et les recommandations cliniques actuelles pour le traitement de l'hypertension, inclure des groupes spécifiques de patients avec des problèmes d’attachement aux traitements, et considérer les résultats cliniques et économiques de l'organisation de soins ainsi que les observations rapportées par les patients. / Objective: Whether interventions including measurement and correction of patients’ attitude to antihypertensive medication can improve hypertension management is unclear. The review aims to determine the effectiveness of patient compliance measurement-guided medication management (CMGM) programs in essential hypertension. Design: Systematic review. Data sources: MEDLINE, EMBASE, CENTRAL, hypertension meetings abstracts, and bibliographies of identified articles. Methods: Randomized controlled trials (RCT) and observational studies (OS) were assessed by 2 reviewers independently. Quality assessment was performed with the Cochrane risk of bias tool and evaluated in a four-point continuum. A narrative data synthesis was performed due to significant heterogeneity among studies. Results: 13 studies (8 RCT, 5 OS) involving 2150 hypertensives were included. Five trials of CMGM with electronic devices as a sole intervention suggested decrease in blood pressure (BP) but the result may have been due to bias. Short-term BP improvement under CMGM in complex interventions was revealed in 4 studies of low-to-moderate quality. In 4 integrated care studies of higher quality the impact of CMGM component was not possible to distil and may be compromised by medication regimens. Regular feedback to the treating physician seems to be an essential component of CMGM and may be effectively mediated by a nurse or a pharmacist and via telecommunication. Conclusions: No convincing evidence for the effectiveness of CMGM as a health technology was found due to non-optimal study designs and methodological quality. Future research should follow accepted quality standards and current guidelines for the treatment of hypertension, include specific groups of patients with compliance problems and consider clinical, economic, patient-reported and organizational outcomes.

Objectif principal: Il n’est pas démontré que les interventions visant à maîtriser voire modérer la médicamentation de patients atteints d’hypertension peuvent améliorer leur gestion de la maladie. Cette revue systématique propose d’évaluer les programmes de gestion contrôlée de la médicamentation pour l’hypertension, en s’appuyant sur la mesure de l’observance des traitements par les patients (CMGM). Design: Revue systématique. Sources de données: MEDLINE, EMBASE, CENTRAL, résumés de conférences internationales sur l’hypertension et bibliographies des articles pertinents. Méthodes: Des essais contrôlés randomisés (ECR) et des études observationnelles (EO) ont été évalués par 2 réviseurs indépendants. L’évaluation de la qualité (de ce matériel) a été réalisée avec l’aide de l’outil de Cochrane de mesure du risque de biais, et a été estimée selon une échelle à quatre niveaux de qualité Une synthèse narrative des données a été effectuée en raison de l'hétérogénéité importante des études. Résultats: 13 études (8 ECR, 5 EO) de 2150 patients hypertendus ont été prises en compte. Parmi elles, 5 études de CMGM avec l’utilisation de dispositifs électroniques comme seule intervention ont relevé une diminution de la tension artérielle (TA), qui pourrait cependant être expliquée par les biais de mesure. L’amélioration à court terme de la TA sous CMGM dans les interventions complexes a été révélée dans 4 études à qualité faible ou modérée. Dans 4 autres études sur les soins intégrés de qualité supérieure, il n'a pas été possible de distinguer l'impact de la composante CMGM, celle-ci pouvant être compromise par des traitements médicamenteux. L’ensemble des études semble par ailleurs montrer qu’un feed-back régulier au médecin traitant peut être un élément essentiel d’efficacité des traitements CMGM, et peut être facilement assuré par une infirmière ou un pharmacien, grâce à des outils de communication appropriés. Conclusions: Aucune preuve convaincante de l'efficacité des traitements CMGM comme technologie de la santé n’a été établie en raison de designs non-optimaux des études identifiées et des ualités méthodologiques insatisfaisantes de celles-ci. Les recherches futures devraient : suivre les normes de qualité approuvées et les recommandations cliniques actuelles pour le traitement de l'hypertension, inclure des groupes spécifiques de patients avec des problèmes d’attachement aux traitements, et considérer les résultats cliniques et économiques de l'organisation de soins ainsi que les observations rapportées par les patients. / Objective: Whether interventions including measurement and correction of patients’ attitude to antihypertensive medication can improve hypertension management is unclear. The review aims to determine the effectiveness of patient compliance measurement-guided medication management (CMGM) programs in essential hypertension. Design: Systematic review. Data sources: MEDLINE, EMBASE, CENTRAL, hypertension meetings abstracts, and bibliographies of identified articles. Methods: Randomized controlled trials (RCT) and observational studies (OS) were assessed by 2 reviewers independently. Quality assessment was performed with the Cochrane risk of bias tool and evaluated in a four-point continuum. A narrative data synthesis was performed due to significant heterogeneity among studies. Results: 13 studies (8 RCT, 5 OS) involving 2150 hypertensives were included. Five trials of CMGM with electronic devices as a sole intervention suggested decrease in blood pressure (BP) but the result may have been due to bias. Short-term BP improvement under CMGM in complex interventions was revealed in 4 studies of low-to-moderate quality. In 4 integrated care studies of higher quality the impact of CMGM component was not possible to distil and may be compromised by medication regimens. Regular feedback to the treating physician seems to be an essential component of CMGM and may be effectively mediated by a nurse or a pharmacist and via telecommunication. Conclusions: No convincing evidence for the effectiveness of CMGM as a health technology was found due to non-optimal study designs and methodological quality. Future research should follow accepted quality standards and current guidelines for the treatment of hypertension, include specific groups of patients with compliance problems and consider clinical, economic, patient-reported and organizational outcomes.