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Research Proposal: Exploring the Barriers and Facilitators in Medications Adherence in the Elderly Population Deborah Aderin, R.N., BSN Molloy College November 29, 2011

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ABSTRACT Introduction: The purpose of this study is to explore the perspective of medication adherence in the elderly population, regarding the factors they perceive as barriers or facilitators of adherence to prescribed medications. Methods: A prospective ethnographic study was conducted using a semi-structured interview guide, consisting of ten open-ended questions about their perceptions to medications, their reasons for adherence and nonadherence, and the effectiveness of strategies participants had tried to improve adherence. Participants: A total of ten community-dwelling seniors, aged 65-84, currently on 4-12 medication daily, and have 3-9 comorbidities. Approach: Qualitative analysis using comparison to explain the influences and hindrances to prescribed medications. Results: Analysis of the data from the respondents identified the factors that influenced adherence to the prescribed medications: beliefs in importance of medications, beliefs regarding medication and health, relationship with health care providers, socioeconomic effects and the strategies to improve adherence. Discussion: The World Health Organization states that compliance to a prescription medicine regimen is one of the most critical issues to the continued health and wellness of old people. Creating a system to remind and motivate towards medication adherence can be a key factor keeping the elderly safe and free of medication errors (Elliot et al., 2007). The elderly and their caregivers require education concerning their beliefs towards medication adherence, the effects of the medications, and how to manage the side effects of the medications (Kripalani et al.,

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2006). Implementation of different strategies will have a positive influence on the occurrence of side effects and improve medication adherence (Ownby et. al., 2005). Different factors influence adherence to the prescribed medications. These factors could be either internal or external factors which forces this population to prioritize their medications. Lack of communication with their health care providers to discuss the cost of the medications and the unpleasant side effects were also identified as key leading factors to adherence (Elliot et al., 2007). Studies among lowliteracy population have demonstrated medications nonadherence due to lack of adequate knowledge to the disease process, the medication management, and inability to identify their medications. Strategic approaches are required for this population to enhance adherence to medications (Kripalani et al., 2006). The relationships between medication adherence and purposeful actions, patterned behaviors and demographic questionnaire were established in the study conducted by Lehane and McCarthy (2007). The communication gap between the elderly and their physicians was seen as a deterrent to medications compliance; in addition patients who had issues with their medications felt uncomfortable discussing the issues with their physicians (Wilson et al., 2007). This study is designed to explore the barriers and the facilitators that influence adherence to medications from the perspectives of the elderly, and to explore what perceptions this population has about the strategies they have tried in the past to improve adherence. This study builds on previous studies by providing a better understanding of how the elderlys perceptions and personal experiences influence their responsiveness to various strategies to improve adherence.

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KEY WORDS: patient compliance, medication adherence, patient education, chronic illness, physicians-patients relations RESEARCH QUESTIONS Two research questions were addressed in the study: What are the challenges affecting medication adherence among the elderly populations in the community? What strategies can be applied to improve medication adherence among the elderly population? LITERATURE REVIEW In a comprehensive review of medication adherence in the elderly, the literature selected focused on studies that examined the factors that influence medication adherence in elderly adults. The factors examined are the elderly adults beliefs regarding medications and health, beliefs, in the importance of taking medications, relationship with health care providers, and strategies for improving adherence. Beliefs Regarding Medications and Health Many factors have attributed to patient beliefs and knowledge regarding medication adherence. The Health Belief Model, implied that adherence to medication is related to the perception of their illnesses; focusing on patients beliefs and illnesses is required to understand adherence in this population (Ownby et al., 2006). Studies have demonstrated that elderly adults with multiple chronic illnesses make choices between their medications. They exhibit nonadherence to medications based on the negative experiences they had in the past, and they

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choose the medications that they felt had the best symptom control, minimal side effects and resistance (Elliot et al., 2007). Patient knowledge and understanding of the disease process and management influences perception to medications adherence. The Medication Adherence Model described medication adherence as to the degree medication is taken intentionally based on the perceived need, effectiveness, and safety (Lehane & McCarthy, 2007). Belief in the Importance of taking Medication The elderly adults were aware of the need to take their medications as prescribed. However, the consequences of adherence were viewed negatively due to the complexity of the regimens, so they prioritize their medications based on their own beliefs and preferences (Wilson et al, 2007). They seek to evaluate or understand their medicines initially before deciding whether to take them, and they experiment with the regimens in various ways from taking breaks with the dosages to complete discontinuation (Elliot et al., 2007). Medications are taken based on the perception that the medications are needed to maintain and promote well-being, and are effective for controlling disease and promoting health (Lehane & McCarthy, 2007). Studies done among the low-literacy population indicated their willingness to take their prescriptions as ordered, but due to inadequate literacy skills they are unable to identify all their medications (Kripalani et al., 2006). Relationship with Health Care Provider Trust in their physicians knowledge and expertise was a key factor in patient adhering to prescribed medications, but when the elderly adults perceived that their physicians prescribes medications without careful consideration of their need for the medications they lose motivation

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(Elliot et al.,2006). Seniors often receive poor medication management due to failure of the physicians to appropriately prescribe and monitor indicated medications (Wilson et al., 2006). The communication gap between physicians and the patients affects adherence, patients who had problems with their medications costs and quality are not courageous enough to share their concerns with the physicians (Ownby et al., 2006; Wilson et al., 2006). Coping Strategies The adherence strategies identified in this study were linked to the medication taking process to help patients and providers recognize where they can use these strategies to improve adherence. Choices are made between medications for different diseases by prioritizing the treatment and choosing between medicines for the same disease, which is influenced by the medicines effectiveness or symptom control (Elliot et al., 2007). Patients wanted medications with fewer side effects, lower costs, or that were perceived to have more effects on their disease, with the best symptom control. Increased cost of the medications resulted in modification of the regimens or rejecting the medications. Communication with physicians about medication costs and adherence is required to understand adherence (Elliot et al., 2007; Wilson et al., 2007). Medication adherence is increased when patients incorporate medications regimens into their daily routine, rely on caregivers, or rely on a mechanical aid such as a pillbox (Ownby et al., 2006).In the absence of cognitive and functional ability to self-administer a medication regimen as prescribed, the ability to identify medications, opening containers, and selecting the proper dose and the time of administration, requires assistance of a caregiver (Kripalani et al, 2006).

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METHODOLOGY Research Design Ethnographic designs are qualitative research procedure used for describing, analyzing and interpreting a culture sharing, a group shared pattern of behavior, beliefs and language that develop overtime (Polit & Beck, 2012). A prospective ethnographic study design utilizing qualitative data collection methods was used for this study. Semistructured interviews were conducted individually to draw out the participants perceptions about the barriers and facilitators that influence medication adherence among the elderly populations. Ethnography is defined as a branch of human inquiry, associated with anthropology that focuses on the culture of a group of people, with an effort to understand the world view of those under study (Polit& Beck, 2012 p.727). In conducting ethnographic research, using a focus group that involved 1:1 participant interviewer ratio, permits access to the needed information in an economical manner. All participants are encouraged to talk freely about the topic on the guide, enabling the participants the freedom to provide as many illustrations and explanations as they wish (Polit & Beck, 2012). Sampling Plan The participants were recruited from the community, ten elderly adults, five men and five women; they were between the ages of 65-84years.They are from three ethnic groups: four African-Americans, three Caucasians and three Asians. All the participants have three to five chronic illnesses, and are currently taking prescribed medication eight to twelve pills a day. They were made aware that this was a school project, and informed consents were obtained. They

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were contacted concerning the time and date of the interviews on the phone. All the participants were aware of the type of data to be collected, and were also made aware of the total number of the participants in the study. They were all fluent in English, none of them were cognitively impaired, and they were able to manage their own medications independently. The participants were given the same demographic sheet for the basic descriptive of themselves. They were required to circle the appropriate response (See Appendix A). Diagnostic Tools The most clinically applicable assessments of adherence are self-reported questionnaires or interviews, which are methods of collecting data that involve a direct report of information by the person who is being, studied (Polit & Beck, 2012). In this study, the self-reported questionnaire was directed towards medication taking behaviors, under the assumption that those with poor behaviors are more likely to be nonadherant to their medications. Data Collection Procedure In collecting the ethnographic data, the researcher was engaged in field work to find out the activities of the participants as well as the physical characteristics of the situation. The data collection started with an overview comprised of broad description observation. Then after analyzing the data, the semi-structured interview was conducted using open-ended questions (See Appendix B) The participants were seen in their individual homes on the set date and time. The purpose and the participants role were discussed. The participants were informed of their right to stop the interview anytime they choose to. Written consent was obtained and the participants

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were informed that the session would be recorded using pencil and paper, and the confidentiality of the data would be maintained. They were made aware that the interview may last between 4560 minutes. They were given full assurance that there would not be any right or wrong answers, only different experiences and points of views. They were encouraged to share their experiences with all their medications regimens, treatment plans, relationships with their physicians and the different approaches they have been using for their medication managements. At the conclusion of each interview, the participants were given a thank you card and a bottle of water. The open-ended questions were formulated from the previous studies conducted to obtain each of the individuals perceptions on medication adherence barriers and facilitators. Each of the participants had adequate time to discuss their thoughts, beliefs and opinions concerning medication adherence. Data Analysis This is the systematic organization and synthesis of research data (Polit & Beck, 2012). In this study the Leininger method that has a four- phase ethno-nursing data analysis guide was used. The first phase, the researcher collect, describes and record data. The second phase involves identifying and categorizing descriptors. In the third phase, data are analyzed to discover repetitive patterns and the fourth and final phase involves major themes and findings will be presented (Polit & Beck, 2012).In the first phase of this study, the researcher collected the raw data from each of the participants, recorded and transcribed verbatim for each participant. In the second phase, the significant statements were extracted from each description, grouped together and the elimination of statements or phrases that have same meaning was done. The third phase involved analysis of the data to extract the hidden meaning of various contexts

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from the data. Lastly, the clustering of the themes was organized from the aggregated formulated meanings. This allowed the emergence of themes common to all of the participants descriptions. Five major themes were identified concerning medication adherence after the data collected were identified and analyzed. RESULTS In seeking the barriers or the facilitators to medication adherence, the interview questions captured the participants experiences as follows: Belief in the importance of taking medications Participants reported how their beliefs about disease processes, taking medications and adverse events contributed to nonadherence of their prescribed medications. All the participants were able to identify the total number of their prescriptions. Some of them were able to explain the purpose of each of the prescribed medications. Some of the participants were fully aware of their chronic conditions, and demonstrated their willingness in taking their medications as prescribed. They acknowledged taking precautions in avoiding duplicating or omitting doses, attended to possible ill effects, and developed measures to assure continuing availability of their medications. The participants with the poorest understanding admitted to frequent nonadherence and forgetfulness regarding their medication. Belief regarding medications and lifestyle Some of the participants identified some degree of reluctancy in adhering to their medications due to the amount of medications to be taken daily. Some participants reported that they tried to take some of their pills in the morning with breakfast, but most of the time they are

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not home for the afternoon dosages. Some participants did not like the idea of taking medications because they viewed medications as artificial and thought they had unpredictable effects. Some of the participants that identified their objections to adherence to the prescribed medications believed that changes in their lifestyle could reduce the progression of their chronic illnesses. Relationship with health care providers There are many responses concerning how the participants interactions with their physicians influence their adherence, communication skills and the complexity of the prescribed regimens. Multiple medications with multiple complexities were reported to be a contributor to adherence problems. Most of the participants acknowledged to be seeing more than two physicians that give prescription for each of their chronic illnesses. However, they dont discuss each of their prescriptions with the primary care providers. Some of the participants believed that physicians were medications advocate which are prescribed too readily. Some of the participants expressed how their physicians rush through the clinic visits, and they are left without the opportunity to express their concerns about the effects of the prescribed medications. Some of the participants expressed how their physicians are very judgmental when they confided in their health care provides about the difficulties they are experiencing with their medications, and how they needed suggestions for the management. Health care system On the healthcare system level, some of the participants reported issues with the cost, formulary restrictions, insurance coverage, and their concerns navigating the medical system. The Medicare beneficiaries with low literacy skills reported their likelihood of adhering to the

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prescribed medications. They reported how the health care delivery system is forcing them to depend on family members to help them adhere to their regimens. Some of the participants expressed how their financial status gets in the way of their medication adherence, such as running out of medications, co-payments issues, and transportation problems. Some of the participants with Medicare beneficiaries described how they are skipping their dosages to make their prescription last longer. Some other participants also talked about how they spread a month refill to three months. Coping strategies Some of the participants discussed the challenges they encounter due to their functional and cognitive status. They highlighted problems remembering their medication regimens, poor motor skills and poor visual acuity. The participants described the different strategies they have been using in managing their medications. Some of the participants stated how they are using the pill boxes, clustering their medications to reduce the frequencies, using electronic reminders and relying on their primary caregiver for assistance. DISCUSSION The results of this study provide an in-depth understanding of how elderly perceptions and experiences facilitated or detracted from adherence to the prescribed medications. The majority of the participants had perfect understanding of how to take their medications. Although, most of the participants of this study could correctly name and describe their medications and the regimens, but they have limited understanding to the purpose of the medications. This group was considered more adherent compared to those participants with poor

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understanding that admitted to frequent nonadherence due to forgetfulness. Relationship with the physicians influenced how patients view medications adherence. Health care providers willingness to spend time explaining medication to patients and providing follow-ups, motivated patients to adhere to the complex regimens. Patients with established knowledge foster independence of managing their medications. Communication between the patients and their health care providers will allow assessment of the effectiveness of their medications; this approach will motivate patients to follow the proper management of the regimens (Ownby et. al, 2006; Wilson et. al, 2007). The medication adherence share core concepts with the Medication Adherence Model, which describes the dynamic process of initiating and maintaining adherence to medications. The model recognizes that patients adherence is predicated on the decision to take medications based on perceived need, effectiveness, and safety ( purposeful action); that patients establish medication-taking patterns through systems and routines (patterned behavior); and that patients use information, prompts and even to re-assess whether they will remain adherent to medications ( Lehane & McCarthy,2007). The coping strategies used by the elderly adults facilitate adherence. The complexity of the regimens are simplified by the use of pillboxes, blister packaging analogous done by the pharmacist to package a days worth of medication. Monitoring and feedback of adherence data from pharmacy database is another promising modality for improving medication adherence because its provides longitudinal feedback on adherence. (Elliot et al., 2007; Kripalani et al., 2006).

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The results of this study may not be generalized to other population of elderly people because the researcher selected the participants. The probabilities that the participants had good medication understanding and especially pronounced misunderstanding may have been overrepresented because of selection factors. IMPLICATIONS Nursing Practice Medication reconciliation should be done at all time to promote compliance to all prescribed medication. Patient knowledge to the purpose, side effects and medication managements should be included in patient care management. The drug utilization should be reviewed at the initial contact with patients, when any alterations are made to the patient plan of care.Medication updates should be made available to clinicians to increase their knowledge to the new medications in the market. In situation where patients are congnitivel impaired,the nurse should consider the appropriate intervention needed such as pillboxes, electronic reminders, calendars, and involvement of a caregiver. Nursing Education Currently, courses in patients education and adherence promotion are incorporated into the curriculum, but there are major gaps. In closing the education gap, the curriculum, will allow nursing students to conceptualize and execute responsible medication-related problem solving on behalf of individual patients. The curriculum should be designed to produce graduates with sufficient knowledge and skills to provide patients with adherence education and counseling.

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Nursing Research Many studies have been done to understand medication adherence in the clinical settings, however, more research is needed to address some critical areas. One of the issues is coming to a consensus on how to uniformly report measures so it could be much easier to compare adherence rates across studies and conditions. New strategies to improve medication adherence need to be tested, and added to the current knowledge base in improving medication adherence and persistence. The health care system need to generate funds that will foster implementation of evidence-based strategies to reduce number of daily doses of medications, organizing medications in pillboxes, motivation interviews and educating patients on the importance of medication adherence. CONCLUSION A majority of people over the age of 65years had good understanding of the drugs they were taking. Substantial percentages showed either limited or global misunderstanding of their medications. By identifying specific types of medications misunderstanding in the elderly, the clinicians may be better able to direct interventions

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APPENDIX : A Demographic Data The Demographic Data Sheet. What is your age? 60 - 65 66 -70 71- 75 76 - 80 81 85 86 -90

What is your ethnic background? White (Caucasian) Black (African-American) Hispanic (Latino) Asian Other

What is your gender?

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Male Female

What is your highest level of education? None Elementary High School

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APPENDIX B Open-Ended Questions Belief in the importance of taking medications for chronic illness 1) How many medications are you taking? 2) Can you tell me why you are taking these medications? Belief regarding medication and health 3) How effective are these medications concerning your illnesses? 4) How often do you take your medications? Relationships with health care providers 5) How many physicians do you see for your prescriptions? 6) How often do you discuss your concerns about your medications with your physicians? Health care system 7) How much do you spend on your medications? 8) How often do you pick your refills from the pharmacy? Coping strategies 9) What have you being doing as a reminder to take your medications?

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10) How do you adjust to the medication routine

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REFERENCES Elliot, R., Degnan, D., Adams, A., Safran, D., & Soumerai, S. (2007). Strategies for coping in a complex world: Adherence behavior among older adults with chronic illness. Society of General internal Medicine. 22: 805-810. Kripalani, S., Henderson, L., Chiu, E., Robertson, R., Kolm, P., & Jacobson, T.(2006). Predictors of medication self-management skill in a low-literacy population. ` Journal of Internal Medicine. 21:852-856

Lehane, E., & McCarthy, G. (2007). An examination of the intentional and unintentional aspects of medication non-adherence in patients diagnosed with Hypertension. Journal of Clinical Nursing .doi:10.1111/j.1365-2702 Ownby, R.L., Hertzog, E.,Crocco., & Duara, ( 2005). Factors related to medication adherence in memory disorder clinic patients. Journal of Aging and Mental Health. 10 (4): 378-385. Polit, D. F., & Beck, C.T. (2012). Nursing research: Generating and assessment evidence For nursing practice (8th ed). Philidephia: Lippincott, Williams & Williams. Wilson,I., Schoen, C., Neuman,, P., Strollo, M., Rogers, W., Chang, H., & Safran, D., (2007). Physcian-patient communication about prescription medication nonadherence:

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RESEARCH PROPOSAL A 50-state study of Americas seniors. Journal of general Internal Medicine. 22: 6-12 World Health Organization (2006). Adherence to long-term therapies: Evidence for action. WHO Publication, Geneva.

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