Validation of the Identification of Medication Adherence Barriers Questionnaire (IMAB-Q); a Behavioural Science-Underpinned Tool for Identifying Non-Adherence and Diagnosing an Individual's Barriers to Adherence.

Purpose: To validate the Identification of Medication Adherence Barriers Questionnaire (IMAB-Q) as a tool to guide practitioners to identify patients who require support to take their medicines as prescribed, their key barriers to adherence and select relevant behaviour change techniques. Patients and Methods: Adults prescribed medication for cardiovascular disease prevention were recruited from nine community pharmacies in England. Participants completed the IMAB-Q comprising 30 items representing potential barriers to adherence developed from our previous mixed methods study (scoping review and focus groups) underpinned by the Theoretical Domains Framework. Participants also self-reported their adherence on a visual analogue scale (VAS) ranging from perfect adherence (100) to non-adherence (1). A subgroup of 30 participants completed the IMAB-Q twice to investigate test-retest reliability using weighted Kappa. Mokken scaling was used to investigate IMAB-Q structure. Spearman correlation was used to investigate IMAB-Q criterion validity compared to the VAS score. Results: From 1407 invitations, 608 valid responses were received. Respondents had a mean (SD) age of 70.12 (9.9) years and were prescribed a median (IQ) 4 (3, 6) medicines. Worry about unwanted effects (n = 212, 34.5%) and negative emotions evoked by medicine taking (n = 99, 16.1%) were most frequently reported. Mokken scaling did not organise related IMAB-Q items according to the TDF domains (scalability coefficient H = 0.3 to 0.6). Lower VAS self-reported adherence correlated with greater IMAB-Q reported barriers (rho = -0.14, p = 0.001). Test-retest reliability of IMAB-Q items ranged from kappa co-efficient 0.9 to 0.3 (p < 0.05). Conclusion: The IMAB-Q is valid and reliable for identifying people not adhering and their barriers to adherence. Each IMAB-Q item is linked to a TDF domain which in turn is linked to relevant behaviour change techniques. The IMAB-Q can therefore guide patients and practitioners to select strategies tailored to a patient's identified barriers.

Pilot study to evaluate knowledge of person-centred care, before and after a skill development programme, in a cohort of preregistration pharmacists within a large London hospital.

INTRODUCTION: Aperson-centred approach to healthcare encompasses personalised care, supporting the individual to recognise their strengths and promote their independence. Preregistration pharmacists , who arenew pharmacy graduates undertaking their training year of practice before qualification,may need support embedding this in practice. OBJECTIVE: To explore the knowledge and confidence in person-centred care (PCC) in a cohort of 12 preregistration pharmacists before and after receipt of an inhouse pharmacy-focused skill development programme using qualitative and quantitative measures. METHODS: Two half-day skill development sessions were delivered to 12 preregistration pharmacists. Assessment forms were completed before and after the skill development sessions, including quantitative data gathered via Likert scales and qualitative, narrative responses. Responses were coded and classified into themes. Participants submitted one written reflective account demonstrating the use of PCC in medicines-related patient consultations following completion of the skill development programme. RESULTS: Assessment forms were received from all participants. Self-reported knowledge of PCC improved from the start of the first session to the end of the second session. The average score for the understanding of PCC rose from 6.5 to 9.6 (Likert scale of 0-10) to the end of the second session. Qualitative analysis identified five person-centred themes, including active listening, using open questions, supporting and empowering patients, developing a shared agenda, and encouraging patients to take ownership of their medicines. CONCLUSIONS: Confidence and knowledge increased from the start of session 1 to the end of session 2. and analysis of the reflective accounts and themes also identified increased knowledge of PCC. This work aligns with previous hospital trust work, which identified that a training programme increased awareness and provided foundation knowledge. A short programme to develop PCC skills was effective in improving the PCC knowledge of 12 preregistration pharmacists. A review of pharmacists' written accounts of their consultations suggests that these skills were integrated into practice.

Developing person-centred consultation skills within a UK hospital pharmacy service: evaluation of a pilot practice-based support package for pharmacy staff.

A person-centred approach to care is central to NHS England's health policy agenda and a standard for pharmacy practice from the General Pharmaceutical Council. Health coaching is a method of delivering person-centred care. A pilot of a health coaching support package, including a 2-day course and practice-based follow-up, was delivered to 70 London North West Healthcare NHS Trust pharmacy staff between December 2015 and July 2017. OBJECTIVES: To evaluate the support package, identifying key themes from course feedback, evaluating staff perception and evidence of application in practice. To identify key benefits of the support package. METHODS: Qualitative analysis of written course feedback was undertaken to identify staff learning themes about person-centred care. The themes were used to design a survey, administered to support package recipients (staff), exploring staff perception of the package. Qualitative review of written examples highlighted use of person-centred themes in practice. RESULTS: Twelve person-centred themes emerged from 49 course evaluations forms, describing what participants learnt about patient-centred care. Of 24 surveys completed, respondents reported increased awareness of themes; however, use in practice varied between themes. Overall, respondents valued the support package and rated practice-support more highly than the course for ongoing development. Patient examples described the use of themes in practice. CONCLUSIONS: The support package increased awareness of person-centred themes, portrayed within the practice examples submitted. While the course provided a foundation for use of a person-centred approach, continuing practice-based support is desired by staff to embed learning into day-to-day practice.

Barriers to medication adherence in patients prescribed medicines for the prevention of cardiovascular disease: a conceptual framework.

OBJECTIVES: To identify barriers to medication adherence in patients prescribed medicines for the prevention of cardiovascular disease and map these to the Theoretical Domains Framework (TDF), to produce a conceptual framework for developing a questionnaire-based medication adherence tool. METHODS: A scoping review of barriers to medication adherence in long-term conditions was conducted to generate an initial pool of barriers. After preliminary mapping to the TDF, these barriers were presented to two focus groups of patients prescribed medicines for the prevention of cardiovascular disease (n = 14) to stimulate discussion. The group discussions enabled the patients' interpretations of the adherence barriers to be determined, provided validity from the patient perspective and identified additional barriers unrepresented in the scoping review. KEY FINDINGS: The preliminary pool of adherence barriers was identified from 47 studies across a range of long-term conditions. The majority of TDF domains were represented by these literature-identified barriers except 'social/professional role and identity' and 'behavioural regulation'. Barrier mapping was largely endorsed by focus group participants, who also contributed additional barriers, including those relating to not having a 'system' in place for managing their medicines and the negative emotions evoked by medicine taking. CONCLUSION: The TDF enabled full exploration of adherence barriers including those relating to emotions which have received limited attention in the literature. This work has provided a conceptual framework for developing a questionnaire to identify an individual's adherence barriers which may then be coupled with appropriate behaviour change techniques to deliver a theory-based intervention tailored for individual need.

Using Theory to Explore the Determinants of Medication Adherence; Moving Away from a One-Size-Fits-All Approach.

Non-adherence to prescribed medicines has been described as "a worldwide problem of striking magnitude", diminishing treatment effects and wasting resources. Evidence syntheses report current adherence interventions achieve modest improvements at best, and highlight the poor progress toward the longstanding aim of a gold-standard intervention, tailored to meet individual need. Techniques such as motivational interviewing and health coaching, which aim to facilitate patient-centred care and improve patient resourcefulness, have shown promise in supporting adherence, especially in patients with psychological barriers to medicine-taking, such as illness perceptions and health beliefs. Despite a plethora of research, there is little recognition that the nature and complexity of non-adherence is such that a one-size-fits-all approach to interventions is never likely to suffice. This commentary re-visits the call for adherence interventions to be tailored to meet individual need, by considering what this means for day-to-day practice and how this can be achieved. It provides an update on advances in psychological theory to identify the root cause of an individual's non-adherence to encourage matching of provided adherence support. It also provides a practical perspective by considering exemplars of innovative practice and evaluating the day-to-day practicalities of taking a novel approach.

A meta-analysis of cognitive-based behaviour change techniques as interventions to improve medication adherence.

OBJECTIVE: To describe and evaluate the use of cognitive-based behaviour change techniques as interventions to improve medication adherence. DESIGN: Systematic review and meta-analysis of interventions to improve medication adherence. DATA SOURCES: Search of the MEDLINE, EMBASE, PsycINFO, CINAHL and The Cochrane Library databases from the earliest year to April 2013 without language restriction. References of included studies were also screened to identify further relevant articles. REVIEW METHODS: We used predefined criteria to select randomised controlled trials describing a medication adherence intervention that used Motivational Interviewing (MI) or other cognitive-based techniques. Data were extracted and risk of bias was assessed by two independent reviewers. We conducted the meta-analysis using a random effects model and Hedges' g as the measure of effect size. RESULTS: We included 26 studies (5216 participants) in the meta-analysis. Interventions most commonly used MI, but many used techniques such as aiming to increase the patient's confidence and sense of self-efficacy, encouraging support-seeking behaviours and challenging negative thoughts, which were not specifically categorised. Interventions were most commonly delivered from community-based settings by routine healthcare providers such as general practitioners and nurses. An effect size (95% CI) of 0.34 (0.23 to 0.46) was calculated and was statistically significant (p < 0.001). Heterogeneity was high with an I(2) value of 68%. Adjustment for publication bias generated a more conservative estimate of summary effect size of 0.21 (0.08 to 0.33). The majority of subgroup analyses produced statistically non-significant results. CONCLUSIONS: Cognitive-based behaviour change techniques are effective interventions eliciting improvements in medication adherence that are likely to be greater than the behavioural and educational interventions largely used in current practice. Subgroup analyses suggest that these interventions are amenable to use across different populations and in differing manners without loss of efficacy. These factors may facilitate incorporation of these techniques into routine care.

Capecitabine non-adherence: exploration of magnitude, nature and contributing factors.

OBJECTIVES: The prescribing of oral chemotherapy agents previously available only in the intravenous formulation, such as capecitabine, has afforded many benefits including reduced administration costs and improved patient acceptability. However, it has introduced the new challenge of ensuring patient adherence to therapy. It is therefore necessary to quantify adherence, and with a view to improving services, explore factors that may impact on medication taking behavior. METHODS: Patients with a diagnosis of breast or colorectal cancer and prescribed capecitabine were recruited from a UK teaching hospital. Data regarding self-reported adherence, beliefs about medicines, side effects, and satisfaction with information received about capecitabine were recorded. RESULTS: Non-adherence was reported by 23.3% of the 43 participants. Capecitabine therapy was perceived necessary by 97.6%, but almost one-third of participants had strong concerns. Side effects were reported by 80% of participants, with Palmar-Plantar erythrodysesthesia and fatigue most troubling participants. Complete satisfaction with information received was reported by 65% of participants; however, dissatisfaction about how to tell if capecitabine is working and the proposed duration of therapy was expressed by 42.9% and 37.3% of participants, respectively. CONCLUSIONS: Adherence to capecitabine is high with a strong conviction that the therapy is necessary. However, concerns were expressed regarding the experience of side effects. Patients have unmet information needs regarding the processes involved with monitoring capecitabine efficacy and determination of therapy duration. Healthcare professionals may therefore wish to consider a greater focus on involving patients in the monitoring of their care with respect to efficacy and planned treatment schedules.