Introduction
Methods
Search Strategy and Selection Process
Criteria for Study Inclusion and Exclusion
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Studies with a sample of stroke survivors or mixed transient ischaemic attack (TIA)/stroke survivors who were ≥18 years of age and had been prescribed medication(s) that targeted at least one stroke risk factor
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Primary research studies with quantitative research designs measuring at least one psychological determinant and medication adherence
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Studies with a sample of stroke survivors <18 years of age
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Mixed condition samples where stroke only data could not be obtained
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Reviews (systematic, narrative or meta-analytic), studies applying retrospective data collection and qualitative study designs
Data Extraction and Analysis
Data Extraction
Analysis
Quality Assessment
Determinant Mapping
Results
Study Characteristics
Author/country | Design | Participants | Number | Medication adherence measure | Psychological determinants | Psychological determinant measure | Key findings [95% CI] |
P values | % of max quality scorea
|
---|---|---|---|---|---|---|---|---|---|
Sample 1 | |||||||||
Bushnell (2010) / USA [43] | Prospective | Ischaemic stroke (1712) and TIA (465) | 2177 | Comparison- discharge vs. current medications (measured by modified MMAQ) | Understanding how to refill medications | Unclear from paper | OR 1.64 [1.04–2.58] |
P = 0.03 | 61.5 |
Understanding why medications are being taken | Unclear from paper | OR 1.81 [1.19–2.76] |
P = 0.006 | ||||||
EQ-5D score | EuroQoL-5D | OR 2.33 [1.24–4.38] |
P = 0.009 | ||||||
Bushnell (2011) / USA [44] | Prospective | Ischaemic stroke and TIA | 2092 | Comparison- discharge vs. current medications (measured by modified MMQ) | Receiving medication instructions | The Primary Care Assessment Survey | OR 1.43 [1.13–1.81] |
P < 0.003 | 61.5 |
Understanding medication side effects | Unclear from paper | OR 1.29 [1.02–1.63] |
P = 0.032 | ||||||
Understanding why medications are being taken | Unclear from paper | OR 1.49 [1.03–2.17] |
P = 0.036 | ||||||
Sample 2 | |||||||||
Edmondson (2013)/ USA [45] | Cross-sectional | TIA and undefined stroke | 535 | 8 item MMAQ | PTSD symptoms | PCL-S | OR 1.02 [1.00–1.05] | 0.1 > p > 0.05c
| 90.9 |
Specific concerns | BMQ (specific) | OR 1.17 [1.10–1.25] |
p < 0.05c
| ||||||
Depressive symptoms | PHQ-8 | OR 1.02 [0.97–1.08] |
p > 0.05c
| ||||||
Kronish (2012)/ USA [36] | Cross-sectional | Undefined stroke | 535 | 8 item MMAQ | Likely PTSD | PCL-S | OR 2.69 [1.71–4.23] |
P < 0.05c
| 90.9 |
Possible PTSD | PCL-S | OR 1.86 [1.27–2.74] |
p < 0.05c
| ||||||
Depressive symptoms | PHQ-8 | OR 1.12 [0.88–1.42] |
p > 0.05c
| ||||||
Kronish (2013) /USA [46] | Cross-sectional | TIA and undefined stroke | 600 | 8 item MMAQ | High concerns about medications | Modified BMQ Specific Concerns (X4 items) | OR 5.09 [2.81–9.24] |
p < 0.001 | 90.9 |
Low perceived need of medications | Modified BMQ Specific Necessity | OR 1.23 [0.79–1.91] |
P = 0.36 | ||||||
Low knowledge of stroke risk factors | NV-Qx1 State 3 most important things would recommend to others to lower stroke risk | OR 1.22 [0.76–1.96] |
P = 0.42 | ||||||
Low trust in personal doctor | Adapted Trust in Doctors Scale (×3 items) | OR 1.30 [0.84–2.01] |
P = 0.23 | ||||||
Perceive discrimination due to race, ethnicity, education, or income | NV-5 point Likert scale | OR 1.79 [1.14–2.81] |
P = 0.01 | ||||||
Phillips (2014) / USA [37] | Cross-sectional | TIA (284) and undefined stroke (316) | 600 | 8 item MMAQ | Necessity beliefs | Adapted BMQ Specific |
β = 0.25 [0.07–0.42] |
P < 0.01 | 72.7 |
Concerns | Adapted BMQ Specific |
β = −0.81 [−0.96 to −0.66] |
P < 0.001 | ||||||
Phillips (2015) / USA [38] | Cross-sectional | TIA (284) and undefined stroke (316) | 600 | 8 item MMAQ | Affective illness items | NV-Q ×1 Level of worry about future stroke |
r = −.27 p = 0.001
β −0.14, R
2 0.02 (F (1, 564) = 12.33) |
P < 0.001 | 72.7 |
Cognitive illness items | NV-Q ×2 How well blood pressure and cholesterol is controlled |
r = 0.29 p = 0.001
β 0.18, R
2 0.03 (F(1, 564) = 22.16) |
P < 0.001 | ||||||
Affective treatment items | BMQ Specific Concerns (×3 items) |
r = −0.40 p = 0.001
β −0.31, R
2 0.08 (F(1, 564) = 56.71) |
P < 0.001 | ||||||
Cognitive treatment items | BMQ-specific necessity (×3 items) + NV-“‘How much do you think medicines can help prevent strokes?” |
r = 0.12 p = 0.01
β 0.13, R
2 0.02 (F(1, 564) = 11.62) |
P < 0.01 | ||||||
Sample 3 | |||||||||
Coetzee (2008) /Australia [39] | Prospective | Ischaemic (14) and haemorrhagic (11) stroke | 25 | Q1 and 2 on TAS Pill Counts | (Partner) Emotional dyscontrol | EFQ |
r = −0.66 |
P < 0.01 | 84.6 |
Language skills | EFQ |
r = −0.44 |
P < 0.001 | ||||||
Memory | EFQ |
r = −0.54 |
P < 0.001 | ||||||
Planning and organisation | EFQ |
r = −0.52 |
P < 0.001 | ||||||
Anger | ESDQ |
r = −0.63 |
P < 0.01 | ||||||
Emotional dyscontrol | ESDQ |
r = −0.76 |
P < 0.001 | ||||||
Helplessness | ESDQ | r = −o.64 |
P < 0.01 | ||||||
Inertia | ESDQ |
r = −0.61 |
P < 0.01 | ||||||
Fatigue | ESDQ |
r = −0.52 |
P < 0.01 | ||||||
Indifference | ESDQ |
r = −0.54 |
P < 0.01 | ||||||
EUPHORIA | ESDQ |
r = −0.51 |
P < 0.01 | ||||||
(Partner) Emotional dyscontrol | ESDQ |
r = −0.51 |
P < 0.001 | ||||||
(Partner) Inertia | ESDQ |
r = −0.51 |
P < 0.01 | ||||||
Anxiety | HADS |
r = −0.74 |
P < 0.001 | ||||||
Specific necessity | BMQ Specific |
r = −0.53 |
P < 0.01 | ||||||
Care received at home | Questions in TAS |
r = 0.53 |
P < 0.01 | ||||||
Sample 4 | |||||||||
O’Carroll (2011) /UK [13] | Prospective | Ischaemic stroke | 180 | Urine samples MARS | Specific medication concerns | BMQ Specific |
β = −0.254 |
P < 0.01 | 76.9 |
MMSE score | MMSE |
β = 0.000 NS
|
p > 0.05c
| ||||||
Perceived benefit of medication | NV-Adapted Q.sd
|
β = 0.273 |
P < 0.001 | ||||||
RMBT score | RBMT |
β = 0.167 NS
|
p > 0.05c
| ||||||
Risk perception of further stroke | NV-Visual analogue 0–100 scale |
β = −0.044 NS
|
p > 0.05c
| ||||||
Illness perceptions-acute/chronic timeline | IPQ |
β = 0.002 NS
|
p > 0.05c
| ||||||
Illness perceptions- treatment control | IPQ |
β = −0.021 NS
|
p > 0.05c
| ||||||
Specific necessity | BMQ specific |
β = −0.022 NS
|
p > 0.05c
| ||||||
Desire for medications now | NV-Adapted Q.s1
|
β = −0.140 NS
|
p > 0.05c
| ||||||
HADS total | HADS |
β = 0.064 NS
|
p > 0.05c
| ||||||
Sample 5 | |||||||||
Glader (2010) /Swedenb[40] | Prospective | Ischaemic and undefined stroke | 21,077 | Data Linkage- RiksStroke with the Swedish Prescribed Drug Register | Support of next of kin | Items from the RiksStroke Register | AH: OR 1.13 [1.02–1.25] S: NS
AP: NS
W: OR 0.98 [0.76–1.26] |
p ≤ 0.001
p > 0.05c
p > 0.05c
P ≤ 0.05 | 69.2 |
Self-perceived general health | Items from the RiksStroke Register | AH: OR 0.86 [0.76–0.98] S: OR 0.69 [0.59–0.80] AP: OR 0.79 [0.70–0.89] W: NS
|
P ≤ 0.02
P ≤ 0.001
P ≤ 0.001
p > 0.05c
| ||||||
Low mood | Items from the RiksStroke Register | AH: OR 0.88 [0.79–0.98] S: OR 1.12 [0.98–1.28] AP: OR 0.92 [0.83–1.02] W: NS
|
p ≤ 0.001
P < 0.09
P ≤ 0.04
p > 0.05c
| ||||||
Satisfaction with hospital care and support | Items from the RiksStroke Register | AH: NS
S: NS
AP: NS
W: NS
|
p > 0.05c
p > 0.05c
p > 0.05c
p > 0.05c
| ||||||
Sample 6 | |||||||||
Sjölander (2011) /Swedenb [41] | Prospective | Ischaemic stroke (men: 9331; women: 9016) | 19,347 | Prescription refills | Self-reported depression | Items from the RiksStroke Register | Men: PR 0.96 [0.88–1.05] Women: PR 1.00 [0.93–1.08] |
p > 0.05c
p > 0.05c
| 69.2 |
Self-reported bad general health | Items from the RiksStroke Register | Men: PR 0.99 [0.90–1.09] Women: PR 0.97 [0.89–1.06] |
p > 0.05c
p > 0.05c
| ||||||
Dissatisfied with care | Items from the RiksStroke Register | Men: PR 0.92 [0.74–1.14] Women: PR 0.93 [0.75–1.16] |
p > 0.05c
p > 0.05c
| ||||||
Dissatisfied with support | Items from the RiksStroke Register | Men: PR 0.99 [0.89–1.10] Women: PR 0.99 [0.90–1.10] |
p > 0.05c
p > 0.05c
| ||||||
Sample 7 | |||||||||
Sjölander (2013) /Sweden [42] | Cross-sectional | Haemorrhagic (40) and undefined stroke (538) | 578 | MARS | Specific necessity | BMQ | OR 0.90 [0.83–0.98] |
P = 0.079 | 84.6 |
Specific concerns | BMQ | OR 1.12 [1.05–1.21] |
P < 0.001 | ||||||
General overuse | BMQ | OR 1.29 [1.14–1.45] |
P < 0.001 | ||||||
General harm | BMQ | OR 1.12 [1.01–1.24] |
P = 0.038 | ||||||
General benefit | BMQ | OR 0.77 [0.68–0.87] |
P < 0.001 |
Measurement of Adherence
Quality Assessment
Determinant Mapping
Domain | Descriptiona
| Determinant |
---|---|---|
Knowledge |
An awareness of the existence of something
| Receiving medication instructions |
Understanding why medications are being taken | ||
Understanding medication side effects | ||
Low knowledge of stroke risk factors | ||
Understanding how to refill meds | ||
Self-perceived general health | ||
Self-reported bad general health | ||
Skills |
An ability or proficiency acquired through practice
| Planning and organisation |
Language skills | ||
Social/Professional role and identity |
A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting
| |
Beliefs about capabilities |
Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use
| Cognitive illness items |
Helplessness | ||
Optimism |
The confidence that things will happen for the best or that desired goals will be attained
| |
Beliefs about consequences |
Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation
| Concerns about medications |
Affective illness items | ||
Beliefs about necessity | ||
Perceived benefit of medication | ||
Cognitive treatment items | ||
Affective treatment items | ||
Risk perception of risk of further stroke | ||
Beliefs about benefit | ||
Beliefs about overuse | ||
Beliefs about harm | ||
Illness perceptions-acute/chronic timeline | ||
Illness perceptions-treatment control | ||
Reinforcement |
Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus
| |
Intentions |
A conscious decision to perform a behaviour or a resolve to act in a certain way
| Desire for medication now |
Goals |
Mental representations of outcomes or end states that an individual wants to achieve
| |
Memory, Attention and Decision processes |
The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives
| MMSE score |
RMBT score | ||
Patient memory | ||
Environmental context and resources |
Any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behaviour
| |
Social influences |
Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours
| Support of next of kin |
Low trust in personal doctor | ||
Perceived discrimination on account of race, ethnicity, education or income | ||
Dissatisfied with care | ||
Dissatisfied with support | ||
Satisfaction with hospital care/support | ||
Care received at home | ||
Inertia | ||
Inertia (rated by partner) | ||
Emotions |
A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event
| Emotional dyscontrol (rated by partner) |
Emotional dyscontrol | ||
Anger | ||
PTSD symptoms | ||
(Self-reported) Depression/depressive symptoms | ||
Low mood | ||
Fatigue | ||
Indifference | ||
Euphoria | ||
Inertia | ||
Inertia (rated by partner) | ||
HADS total | ||
Anxiety | ||
Helplessness | ||
Affective Illness Items | ||
Behavioural regulation |
Anything aimed at managing or changing objectively observed or measured actions
|
Domain | Total no. of determinants tested across all papers | No. of determinants significantly associated with better adherence | No. of determinants significantly associated with worse adherence | No. (%) of determinants tested not significantly related to adherence | No. of the 12 papers reporting a test of at least one determinant from this domain | No. of the 7 samples in which at least one determinant from this domain was tested | No. (%) of samples in which determinants were tested and at least one had a significant association with adherence |
---|---|---|---|---|---|---|---|
Knowledge | 7 | 4 | 1 | 2 (29%) | 5 | 4 | 3 (75%) |
Skills | 2 | 0 | 2 | 0 (0%) | 1 | 1 | 1 (100%) |
Beliefs about capabilities | 2 | 1 | 1 | 0 (0%) | 2 | 2 | 2 (100%) |
Beliefs about consequences | 12 | 4 | 5 | 3 (25%) | 7 | 4 | 4 (100%) |
Intentions | 1 | 0 | 0 | 1 (100%) | 1 | 1 | 0 (0%) |
Memory, attention and decision processes | 3 | 0 | 1 | 2 (67%) | 2 | 2 | 1 (50%) |
Social influences | 9 | 2 | 3 | 4 (44%) | 4 | 4 | 3 (75%) |
Emotions | 15 | 0 | 13 | 2 (13%) | 7 | 4 | 3 (75%) |