Impact of findings on practice
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Practical information about how to fit drugs in daily routines could support patients in their adherence to medication.
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Factors such as information about medication and individual experiences with medication can be related to high as well as low adherence, hence interventions to improve adherence should be tailored to the individual patient.
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Positive and negative experiences of patients and his/her relatives with medication can influence adherence to medication. Exploration of these experiences in counselling can give useful information to support adherence.
Introduction
Aim of the study
Method
Study design
Patient selection
How do patients use/organise their medication |
Experiences with not taking medication |
Reasons for non-adherence |
Factors related to high levels of adherence for medication |
Factors related to lower levels of adherence for medication |
Checklist for possible factors related to high or lower levels of adherence for medicationa
|
Forgetting |
Social environment |
Effect of medication |
Side effects of medication |
Information and knowledge about medication |
Relation with general practitioner |
Complexity of drug regimen |
Analysis
Results
Patient characteristics
Adherenta
| Less adherentb
| |
---|---|---|
Gender | ||
Male | 5 | 5 |
Female | 5 | 5 |
Age, mean (range) | 68 (52–85) | 72 (62–92) |
Number of years diagnosed with diabetes (range) | 6.0 (2–16) | 4.5 (1–10) |
Total | 10 | 10 |
Adherenta
| Less adherentb
| |||
---|---|---|---|---|
ATC-class of drugs (ATC) | Patients (n) | Drugs per patientc (mean, range) | Patients (n) | Drugs per patientc (mean, range) |
Antidiabetic drugs (ATC = A10) | 10 | 1.6 (1–2) | 10 | 1.3 (1–2) |
Alimentary tract and metabolism (ATC = A, without antidiabetic drugs) | 5 | 1 (1) | 6 | 1.2 (1–2) |
Blood and blood forming organs (ATC B) | 4 | 1.3 (1–2) | 3 | 2 (1–3) |
Cholesterol lowering drugs (ATC = C10) | 7 | 1 (1) | 5 | 1 (1) |
Cardiovascular system (ATC = C, all other) | 9 | 2.7 (1–5) | 7 | 1.9 (1–3) |
Analgesics (ATC = M01, N01) | 2 | 1 (1) | 3 | 2 (1–3) |
Respiratory system (ATC = R) | 2 | 1 (1) | 3 | 3 (1) |
Other | 5 | 1.8 (1–3) | 7 | 1.9 (1–4) |
Total | 10 | 7.0 (4–10) | 10 | 6.6 (4–10) |
Aspects emerging from the analysis
Information about the medication
Knowledge about medication was for many patients rather limited, however lack of information was not always considered a limiting factor for adherence by the patients themselves:“Well, it [knowledge about medicines] is important as it concerns the doctor’s advice how to take medicines. You follow his advice… and you read the package leaflet. The pharmacy provides those big information sheets, with everything written clearly. Well you read everything…” (Woman, 62 years, less adherent)
For some patients however, information about the medication and the underlying disease was important and associated with the intention to comply to their medication regimen:Knowledge about medication? I have no idea! I Medicines are prescribed, I use them. That’s it. I never read the package leaflet. When you read it, you lose courage to use them any longer, and in my opinion you have to use them… the colours tell me how: blue is for the prostate, and I have orange and white, and for my sugar I use a tablet somewhat larger. I also have another one for my stomach. (male, 71 years, less adherent)
It [my diabetes related medication] has been explained very well. This disease may damage your veins, your eyes, and even more. It will destroy you: that was explained perfectly. For me it was clear, hence I use my medicines and understand their importance. (male, 52 years, adherent)
Experience with medication and complications with usage
Not only current, but patients’ past experiences with health care affected their adherence. Moreover, experiences of close friends and family members with medication could lead to beliefs in the necessity of treatment that influenced drug adherence. An example was a patient who was motivated to comply with her medication regimen because she had seen the complications of diabetes in her family:If I experience side effects, l stop taking medicines. I don’t feel well. And then, my doctor thinks: what to do next? Usually he prescribes me another drug. (female, 72 years, adherent)
For most patients, using medication in daily practice was complicated. Patients distinguished two aspects: complexity because they had to take medication at different times a day, and complexity in taking the right amount of medication because they had to take more than one drug, or had to perform difficult actions before they could take the drug. Another aspect of the complexity of taking medicines at different times was that this was (more) difficult to schedule. This was problematic for a patient who had to combine oral anti-diabetics with insulin:I had a sister in law, she died recently. It started with losing a toe, then the top of her foot, later her leg till under her knee, and finally she lost her whole leg. Well, now she does not live any more. That frightens me very much. (female, 65, adherent)
Taking the right amount was sometimes complex when patients had to split the tablets themselves, because they had to take another amount than one (whole) tablet.A tablet is easier to take, it doesn’t matter when you take it half an hour earlier or later. But when you inject insulin, it has to be at the right time. You must inject and eat directly. (woman, 65, adherent)
Many patients had experienced a situation in which it was difficult to take all the medication, because of the quantity or because of size. Only in one case it was mentioned this was actually a factor that limited adherence:When you split them [the tablets]—and that is strange—1 day you have three quarters of a tablet and the other day you only have one quarter. You have to cut them on the line of fracture. And I have to use them, you can’t throw it away! (male, 72 years, adherent)
Well he [my husband] says: “that one I won’t take today. That’s such a big one, he will stuck in my throat, and then my throat will be burning.” (partner of patient, 71 years, female, less adherent)
Social support for medication behaviour
However, not every patient had such an opinion of his/her physician, in one extreme case a patient experienced lack of support and this resulted in an repulsive attitude of the patient to her physician:“My point of view is that these people (physicians) have studied, and have proven they can do something in our society. You surrender to them. When he prescribes, who am I to ask: ‘does that drug do anything?’ In the end, I am a layman.” (male, 76 years, less adherent)
Most patients considered their medication their individual responsibility, and help of their partner or children was not needed. For them, support from their social environment was not an issue. Others needed help for practical reasons such as a bad visibility or not being able to get tablets out of the blisters. Also, six patients (five of them males) appreciated help by partners or children, sometimes indolence was the main reason:Well, my GP and I, we don’t like each other. We have had a conflict several times. He can say to me “you should do this or that”, but I will not listen to him! (female, 71 years, less adherent)
Well, I can manage it myself [my medication], but it is very easy when she [his wife] thinks about it! (male, 67 years, adherent)
Routines in medication behaviour
Routines in taking medication were experienced as factors related to higher levels of adherence. Many patients had developed certain habits that were a safeguard to remember their times of intake. Patients were creative in these drug plans:Once in a while you forget [taking your medicines], in certain situations, when you are not at home. You don’t think about the possibility you won’t be at home in advance. (female, 75 years, less adherent)
Another way to fit medication use in the daily regimen was to attune times of intake with common patterns. Daily routines and regularity were related with higher adherence, also in the next patient who was less adherent when she deviated from her daily routines:Well, we put the medicines near the breakfast plates, in sight. So it’s easy to keep in mind In the morning you open the kitchen cupboard and then you remember. (male, 67 years, adherent)
Well, sometimes I forget the drugs to control my sugar. When I am somewhere else it happens that I think: “Oops, I have forgotten my medicines.” …This is what I’m used to do [when I am at home]: get up, go to the bathroom, and take my medicines. It’s quite a ritual, honestly. (female, 72 years, less adherent)