Runninghead: RESEARCH PROPOSAL 1

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 low-

literacy 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 elderly’s 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 45-

60 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 don’t 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 day’s 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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A 50-state study of America’s 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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