TOPIC 29: Medication Adherence – Understand cultural and other factors that may affect medication adherence
OFFICIAL ABP TOPIC:
Understand cultural and other factors that may affect medication adherence
BACKGROUND
Medication adherence refers to whether patients take their medications as prescribed and continue taking them over time. It involves decisions and behaviors that can be influenced by the healthcare system and cultural and socioeconomic factors. Understanding these multifaceted influences is important for recognizing and addressing barriers to adherence.
MEDICATION NONADHERENCE FACTORS
In 2003, the WHO published a report on medication nonadherence that categorized contributing factors into the following dimensions:
|
CATEGORY |
EXAMPLES |
|
Health System |
– Poor provider-patient communication – Limited access to healthcare services and medication refills – Lack of care coordination during transitions (e.g., post-discharge confusion about medication regimen) |
|
Patient |
– Physical impairments (e.g., vision issues, dexterity problems) – Cognitive impairment (e.g., forgetfulness) – Depression and mental health conditions – Mistrust in the healthcare system, especially in minority populations |
|
Condition |
– Asymptomatic chronic diseases (e.g., hypertension, hyperlipidemia) where patients feel less motivated to take medications – Chronic illnesses requiring long-term therapy – Mental health conditions such as depression or anxiety |
|
Therapy |
– Complex regimens (e.g., polypharmacy, multiple daily doses) – Frequent dosing schedules causing unintentional omissions – Side effects (feared or experienced), leading to intentional discontinuation |
|
Socioeconomic |
– Low health literacy impacting understanding of medication instructions – High medication costs and out-of-pocket expenses – Lack of insurance coverage – Poor social or caregiver support, particularly in children and older populations |
CULTURAL FACTORS IN MEDICATION NONADHERENCE
There are multifactorial reasons for healthcare disparities and lower rates of medication adherence across racial and ethnic groups. Cultural factors may play a role in many of the reasons for nonadherence described above, including health system barriers, patient beliefs, and socioeconomic factors.
Perceived discrimination is linked to lower medication adherence and adverse health outcomes. Even providers who explicitly state egalitarian beliefs about race and ethnicity may have implicit biases toward their patients that they are not aware of. For example, studies have shown that providers tend to have different communication patterns with different racial groups, such as more patient-centered communication with White patients compared with Black patients.
Mistrust in the healthcare system is more common in minority populations. An individual may be more likely to mistrust the healthcare system after experiencing personal discrimination or because they are aware of systemic healthcare disparities and historical discrimination. For example, the Tuskegee syphilis study withheld treatment to Black men with syphilis for decades without their knowledge. Black patients are more likely to believe in conspiracy theories about HIV and distrust antiretroviral medications.
While the use of complementary and alternative medicine (CAM), such as herbal remedies, varies across racial and ethnic groups, some groups may be more likely to trust these therapies over traditional medications. For example, one study found that Mexican Americans were more likely than non-Hispanic White patients to use CAM instead of diabetes medications prescribed by their medical providers. Underserved populations may also be more likely to turn to CAM if they lack access to healthcare or find CAM more economical than prescribed medications.
Some minority populations may also be more likely to experience socioeconomic barriers such as poverty or lack of social support that make it difficult to afford medications or copays, access health care, or enroll in health insurance. They may also experience higher rates of depression or other mental health conditions that make medication adherence difficult.
Language barriers in families with low English proficiency may lead to miscommunications about medical conditions and treatment, especially in healthcare settings with limited interpreter services. Children may be inappropriately enlisted to translate for their parents. Even when providers use professional interpreters, they may not be able to spend as much time listening or explaining concepts as they would with a parent who was fluent in English.
Even if families are proficient in English, cultural differences in communication norms can affect understanding of medication instructions and willingness to ask clarifying questions or express concerns.
ADDRESSING MEDICATION NONADHERENCE
By being aware of the many factors that play a role in medication nonadherence, providers can work to address them. Provider training to improve cultural competence, reduce implicit racial bias, and improve patient-centered communication may help reduce perceived discrimination and make it more likely that medication beliefs and concerns are discussed, including the use of complementary and alternative medicine. Open, nonjudgmental communication and patient-centered approaches are key to strengthening the patient-provider relationship and recognizing and overcoming barriers to medication nonadherence.
For patients with limited proficiency in English, professional interpreters should be used. For patients with low health literacy, medical concepts should be explained in ways that ensure patients understand the purpose of medications and the instructions for taking them.
Families with socioeconomic barriers to accessing healthcare and medications should be connected with available community resources and social services for support.
For illnesses that require complex pharmaceutical therapies, simplifying medication regimens by using combination pills or reducing dosing frequency may improve medication adherence as well.
REFERENCES
https://pmc.ncbi.nlm.nih.gov/articles/PMC5789102/
https://iris.who.int/bitstream/handle/10665/42682/9241545992.pdf
https://www.ahajournals.org/doi/10.1161/circulationaha.108.768986