ADHERENCE TO THERAPY POST MYOCARDIAL INFARCTION – Online Homework Help

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The review of the literature should include an analysis/critique of the 3 research studies related to the proposed research study. EACH ARTICLE SHE BE COMPOSED INTO 1 PAGE PAPER 1 PARAGRAPH  FOR 1 ARTICLE SUMMING IT UP ( TOTAL OF 3 ARTICLES…QUANTITATIVE, QUALITATIVE AND LITERATURE REVIEW ARTICLES .

Adherence to health recommendations after
a cardiac rehabilitation programme in
post-myocardial infarction patients: the role
of health beliefs, locus of control and
psychological status
Joyce Leonga, Alexander Molassiotisa,*, Helen Marshb
a School of Nursing, University of Nottingham, Nottingham, UK
b City Hospital, Nottingham, UK
Summary The purpose of this study was to examine the level of adherence to
medical recommendations and health advice among post-myocardial infarction
patients and determine the factors that may influence adherence. This study took a
quantitative approach and structured questionnaires were used with a convenience
sample of 52 patients. All patients reported that they were taking medication as
directed all the time. Most patients were adhering well with a health diet (80.8%
“often” or “all the time”), but lower levels of adherence were observed with
regards to adherence with weight loss (25%), physical activity (65.4%), social activity
(44.2%), smoking cessation (28.8%) and alcohol use (19.2%). Key predictors of
adherence were found to be the extent family members encourage patients to
follow health advice in relation to following a healthy diet, health locus of control
(powerful other) in relation to adherence with weight loss, past medical history,
anxiety and internal health locus of control in relation to adherence with physical
activity, and finally depression, gender and internal locus of control in relation to
adherence with social activities advice. Families should also be part of cardiac
rehabilitation programmes as they can influence adherence, and beliefs or
personality characteristics that influence adherence should be assessed in postmyocardial
infarction patients in order to identify who is more likely to be
nonadherent and thus provide more individualised support.
c 2004 Elsevier Ltd. All rights reserved.
KEYWORDS
Adherence;
Myocardial infarction;
Rehabilitation;
Beliefs;
Locus of control;
Anxiety;
Depression
Introduction
Coronary heart disease is a leading cause of death
in many industrialised countries and is responsible
for considerable distress and disability. For example,
in the United Kingdom, 20.36% of the total
* Corresponding author. Present address: School of Nursing,
University of Manchester, Coupland III, Coupland Street, Manchester
M13 9PL, UK. Tel.: þ44-161-2755337; fax: þ44-161-
2757566.
E-mail address: alex.molassiotis@man.ac.uk (A. Molassiotis).
1361-9004/$ – see front matter c 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cein.2004.02.001
Clinical Effectiveness in Nursing (2004) 8, 26–38
http://intl.elsevierhealth.com/journals/cein
Clinical
Effectiveness
in Nursing
number of deaths are related to coronary heart
disease (British Heart Foundation, 2000). However,
patients who have been appropriately managed
and survive after the onset, progress well if they
have not developed cardiac failure or any serious
arrhythmia. The Department of Health (1999) in
the UK has tried to achieve long-term health gains
by promoting healthy lifestyles and long-term
lifestyle changes following a myocardial infarction.
Cardiac rehabilitation programmes are designed to
educate individuals about epidemiological risk
factors such as high cholesterol, lack of physical
exercise, cigarette smoking and the effects of excessive
alcohol consumption, and the disease process
associated with cardiovascular disease
(Thompson, 1994).
Based on a survey carried out in general practice,
Campbell et al. (1998) concluded that 90% of
patients with previously identified coronary heart
disease have one or more lifestyle related cardiovascular
risk factors which are likely to have contributed
to their heart disease. Such risk factors in
post-myocardial infarction patients may inhibit
recovery and increase the chance of reinfarction.
These lifestyle-related cardiovascular risk factors
include smoking, poor diet, heavy alcohol consumption
and a sedentary lifestyle. Post-myocardial
infarction patients must make many physical as
well as psychological adjustments in their lifestyle
of long duration in order to increase their chances
for the optimal return of cardiac function. This will
then in turn enable them to return to the desired
level of social functions. To achieve this, patients
need to follow health recommendations and advice
and alter their lifestyle. However, people’s willingness
and ability to adopt lifestyle changes is
a complex issue in which lay understandings of
disease causation and risk, and a range of socioeconomic
factors are important (Wiles, 1998).
Haynes et al. (1979) define compliance to
treatment as the extent to which a person’s behaviour,
in terms of taking medications, following
diets or executing lifestyle changes coincides with
medical or health advice. They further explain that
while compliance suggests obedience to health
care professionals, adherence connotes the patient’s
participation and engagement in maintaining
a regimen the patient himself or herself
believes will be beneficial. The latter, therefore,
strongly implies that a therapeutic partnership
with health care providers is essential in order to
ensure the patient’s success in adherence. Studies
have shown that patients who adhere to their
regimens have better outcomes in terms of longevity,
enjoy a better quality of life and suffer less
symptoms than those who do not (Horwitz and
Horwitz, 1993). However, it is well known that
people do not necessarily implement or maintain
recommended changes in lifestyle (McSweeney,
1993; Thompson, 1998).
The level of adherence in the treatment of
chronic illness is quite low (Robertson and Keller,
1992). Both Glasgow et al. (1987) and Kravitz et al.
(1993) reported that adherence to lifestyle recommendations
is poor. Wright (1993) estimated the
percentage of patients who fail to adhere to prescribed
regimen is somewhere between 20% and
80%. Our own work with diabetic, renal dialysis
and HIV-infected patients showed similar patterns
and a range of personality factors contributing to
nonadherence (Chan and Molassiotis, 1999; Lee and
Molassiotis, 2002; Molassiotis et al., 2002). Research
has also shown a clear trend of nonadherence
and high relapse rates to previously
established patterns of behaviour (Cupples and
McKnight, 1994; Lip et al., 1995). Adherence to
hospital-based cardiac rehabilitation programmes
has also been found to be problematic. Oldridge
and Streiner (1990) reported that the drop-out rate
of hospital-based cardiac rehabilitation programmes
can be as high as 50%. Factors such as
age, recommendation from other patients, commuter
time, poor time management, laziness and
convenience, which are all related to hospitalbased
cardiac rehabilitation uptake, can influence
adherence (Ades et al., 1992a).
Horgan et al. (1992) and Harlan et al. (1995)
found that women are less likely to attend cardiac
rehabilitation programmes. Takeda et al. (1996)
reported that even at home, women may not
achieve more than 50% adherence. Brezinka and
Kittel’s (1996) study on rehabilitation outcomes
also revealed poorer programme uptake, poorer
adherence and significantly higher dropout rates
for women. Nonadherence in women may be related
to cultural issues, the higher age of female
patients when they are being diagnosed with coronary
heart disease (Karlson et al., 1994), more
severe pathology than in men (Moore et al., 1998)
or education programmes not meeting their needs
(Moore, 1996; Thompson and Bowman, 1995).
Nonadherence with the exercise component of
cardiac rehabilitation is also a problem because of
the extended period of exercise maintenance that
is required before benefits are achieved (Andrew
et al., 1981). Cardiac patients have often questioned
the safety of the exercise component of the
therapeutic regimen and doubts such as this could
often lead to nonadherence. Furthermore, nonadherence
to diet recommendations may be related
to certain situations such as eating in company,
having too much food available and the perception
Adherence of health recommendations 27
that healthy foods do not taste good (Koikkalainen
et al., 1996). A study showed that the majority of
men hospitalised for myocardial infarction did not
adhere to diet recommendations because they did
not like the taste of the cardiac diet, had difficulty
in choosing the appropriate foods in the supermarket
and had difficulty in adhering with the diet
away from home (Barnes and Terry, 1991). The
majority of patients at a follow-up clinic considered
the recommended cardiac diet boring and still
desired foods not prescribed in their diet (Wright,
1994). Lloyd et al. (1995) found that inferior
quality of food taste was one of the major barriers
to adherence with diet recommendations while
greater cost and lack of family support also hindered
adherence.
Haynes (1976) in a comprehensive review of
determinants of patients’ adherence with therapeutic
regimens, which has challenged many commonly
held assumptions, found over 200 variables
having a relation with adherence. These variables
are generally categorized by Meichenbaum and
Turk (1987) as: characteristics of the patients;
characteristics of the treatment regimen; features
of the disease; the relationship between the health
care provider and the patient and lastly, the clinical
setting.
Davison et al. (1991) have been influential in
explaining social and cultural influences in coronary
heart disease and their research findings
have raised some important issues for health education
programmes, particularly, the fact that
even in today’s scientific world, “luck”, “fate”
and “destiny” still play a part in explanations
about illness and death attributable to heart disease.
According to Murray et al. (2000), patients’
adherence with health care advice offered by
professionals may be seriously undermined due to
lack of attention to individuals as whole persons
within the context of their particular beliefs and
aspirations. The Health Belief Model, commonly
used to explain health behaviours, suggests that
when people are faced with pressure to change
their lifestyle, they tend to weigh up the pros
(benefits) and cons (barriers) of adhering to the
recommended treatment and then make decisions
accordingly (Becker, 1974). Therefore, it is unlikely
that the individual will continue to adhere
to the cardiac rehabilitation programme if the
perception is that the cost of participating in the
programme outweighs the perceived benefits.
The Health Locus of Control (Wallston et al.,
1978) also has been used to predict health behaviours.
The control element relates to the amount of
control individuals feel they have over their cardiac
rehabilitation programme (Thomson, 1999).
Thomson (1999) in his review concluded that within
the framework proposed by Rotter (1966), altering
a patient’s locus of control would potentially improve
adherence by altering the patient’s selfconcept
to incorporate the “at risk” or “recovery”
roles.
Depression is common among patients recovering
from myocardial infarction (Frasure-Smith
et al., 1995). In a review by Carney et al. (1995),
it was pointed out that depression affects outcomes
by reducing adherence to prescribed
treatment regimens during the post-myocardial
infarction period. This is consistent with Carney
et al. (1995) who also reported that depressed
elderly patients with coronary artery disease adhered
less often to prescribed aspirin therapy
compared to patients without depression. However,
in another study, Ades et al. (1992b) neither
found that depression during hospitalization
predicted participation in cardiac rehabilitation
nor subjects with a history of depression prior to
the myocardial infarction were less likely to
participate in cardiac rehabilitation. As there is
disagreement in the literature about the role of
depression in adherence of myocardial infarction
patients, further research in their relationship is
necessary to clarify the issue. Also, during the
past 15 years, there has been little research on
the role of anxiety as a barrier to participation or
adherence to cardiac rehabilitation (Daly et al.,
2002). However, anxiety has been reported by
Conn et al. (1991) as one of the intrapersonal
phenomena that is likely to affect participation
in health behaviours such as complex exercise,
diet, medication, stress-modification and smoking-
cessation components of the cardiac therapeutic
regimen.
Social support is a well-documented valuable
resource directly affecting health and health behaviours
(Conn et al., 1991). There is evidence that
social support affects participation in behaviours
conducive to reduce cardiovascular health risk
(Ben-Sira and Eliezer, 1990). Yates et al. (1994)
also found that patients who have their family’s
support for attending a cardiac rehabilitation programme
are more likely to adhere to the programme
than those who do not. Thomson (1999)
also agreed that spouse or partner support can
improve adherence to rehabilitation.
Thus, the aim of this study was to determine
the level of adherence to medical regimen and
health advice among post-myocardial infarction
patients who participated in a cardiac rehabilitation
programme and assess the role of the factors
reported earlier in the review in influencing
adherence.
28 J. Leong et al.
Methodology
Research design and sample
The study used a quantitative cross-sectional design.
The Cardiac Rehabilitation Unit of a University
Hospital in the UK was selected. Since
adherence has been reported to decline at the
early stages of convalescence (Radtke, 1989), patients
who have been diagnosed with myocardial
infarction and attended a cardiac rehabilitation
programme in the past two years were selected.
The inclusion criteria were: (1) diagnosis of myocardial
infarction three months to two years prior
to the study; (2) absence of major complications
post-myocardial infarction that would make participation
burdensome or impossible; (3) patients
who had attended the cardiac rehabilitation programme,
(4) orientated in time and place; (5) able
to understand English and (6) volunteered to take
part in the study. Out of the 792 patients who were
registered with the Cardiac Rehabilitation Unit
between January 2001 and May 2002, only 89 patients
met the inclusion criteria. Four patients
died while waiting for the research proposal to
be approved. Therefore, only 85 patients were
approached.
Scales used
Adherence scale
The patient self-reported Adherence Scale measures
the respondent’s perception of following
prescriptions of the medical regimen and health
advice and was developed based on a review of the
literature. The seven items included under this
scale were: taking prescribed medication; following
a healthy diet; adherence with weight loss;
adherence with physical activity/exercise; adherence
with advice on social activity; smoking cessation
and alcohol use. Scores could range from 4
to 28 with higher scores indicating more adherence.
Each item was on a 4-point Likert-type scale
ranging from 1¼advice followed none of the time
to 4¼advice followed all the time.
Health beliefs scale
The Health Beliefs Model explains health behaviours
at the level of individual decision making
(Rosenstock, 1974). Rosenstock’s hypothesis is that
if an individual was to behave in ways that would
help him or her avoid a disease, the individual
would have to believe that he or she was personally
susceptible to it; the disease would have serious
consequences; taking a particular action would be
beneficial and the action would not entail overcoming
barriers such as cost, convenience and pain
(Rosenstock, 1974). From the literature review, it
was found that past research suggested that health
beliefs were correlated with behaviour and hence,
could be used to differentiate between those who
did and did not undertake these behaviours. As a
result, the items that were included under the
Health Beliefs Model for this study were the subscale
about barriers, the subscale about selfefficacy
and the subscale about health motivation.
The subscale about barriers provides measures of
the practical barriers of taking a preventive action.
The subscale about self-efficacy provides measures
of the strength of self- and outcome-efficacy beliefs.
Finally, the subscale about health motivation
provides measures of the “cue to action” of taking
a preventive action. Respondents were asked to
indicate their level of agreement with particular
statements by simply ticking the appropriate
box based on a five-point Likert scale ranging
from “strongly disagree”, “disagree”, “neutral”,
“agree” to “strongly agree”. Higher scores are indicative
of a stronger belief. The Cronbach alpha
reliability of the scale with the current sample was
0.71.
Multidimensional health locus of control scale
The Multidimensional Health Locus of Control Scale
(Wallston et al., 1978) provides measures of three
dimensions of health locus of control: Internality
which measures the extent to which an individual
believes the locus of control for health is internal;
Chance, which measures the belief in chance or
external factors in determining health outcomes;
and powerful others which measures the belief in
the control over one’s health of powerful others,
particularly health professionals. Cronbach alphas
reported range from 0.60 to 0.75 and test–retest
reliability ranges from 0.60 to 0.70. Each subscale
consists of six items and a 6-point Likert-type scale
is used. The score on each item ranges from 1 for
“strongly disagree” to 6 for “strongly agree”. The
range of scores for each subscale is therefore from
6 to 36, with higher scores indicating stronger beliefs.
The Cronbach alpha reliability of the scale
with the current sample was 0.70.
Social support
The extent that family members encourage someone
to follow medical recommendations was measured
with one self-developed item. This provides
an indication of social support, commonly seen as
an important factor in other adherence studies.
Higher scores indicate greater levels of support
received.
Adherence of health recommendations 29
Hospital anxiety and depression scale
The Hospital Anxiety and Depression Scale is a
14-item scale which provides a brief measure of
both anxiety (seven items) and depression (seven
items) (Zigmond and Snaith, 1983). The severity
of the states are classified as “normal” (score of
0–7), “mild” (score of 8–10), “moderate” (score
of 11–14) and “severe” (score of 15–21). Concurrent
validity was assessed by comparing the
scores from the scale and psychiatric ratings and
the subscales correlated significantly with these
ratings (anxiety, r ¼ 0:54; depression, r ¼ 0:79)
(Zigmond and Snaith, 1983). The Cronbach alpha
reliability of the scale with the current sample
was 0.89.
Descriptive information was obtained about patients’
sociodemographic data and clinical characteristics.
The sociodemographic data included
gender, age, ethnicity, religion, occupation, level
of education, and socio-economic status while the
clinical characteristics were related to thrombolysis
administered, type of thrombolysis, serum lipid
levels on discharge, past medical history, smoking
habits and alcohol intake. These were retrieved
from the patients’ records.
Procedures
Approval from the local Research Ethics Committee,
the Research and Development Department
and the Consultants in-charge were obtained before
commencing the study. The investigation
conformed with the principles outlined in the
Declaration of Helsinki. The questionnaires were
posted to participants together with a cover letter
from the Cardiac Rehabilitation Coordinator who
was known to the participants. A detailed patient
information sheet was also included. Confidentiality
of the responses was assured. The title of the
study on the information sheet was “An Audit of
the Cardiac Rehabilitation Programme” so as to
avoid biases if the word “adherence” appeared in
the study title. A code number was allocated to
each questionnaire pack. The participants were
instructed to return the completed questionnaire
in the pre-paid self-addressed envelope provided
back to the researchers within 2 weeks. The researchers
followed up with a reminder letter to
participants who had not returned the questionnaire
after 3 weeks. Return of the questionnaires
implied consent.
Two key terms are mentioned throughout the
paper, those of cardiac diet and cardiac rehabilitation
programme and these are explained below.
Most patients seen in cardiac rehabilitation often
demonstrate one or more of the following: being
overweight, hypertensive, diabetic or hyperlipidaemic.
Therefore, the aims of dietary therapy in
cardiac rehabilitation are to ensure a well-balanced
healthy diet; reach and maintain ideal body
weight, and achieve lipids/blood sugar within normal
ranges.
Even though there is good systematic review
evidence that mortality and morbidity can be reduced
and risk factors can be modified in those
with cardiovascular disease, Hooper (2001) found
evidence that current dietetic practice does not
comply completely with this best evidence. As a
result, Hooper (2001) recommended that dietetic
departments examine their practice.
In the hospital where the study was carried
out, only patients with complications post-myocardial
infarction, other medical conditions except
diabetes mellitus or those who are
problematic in terms of personality or who have
cardiac misconceptions are reviewed by the dietitian
during cardiac rehabilitation. Patients who
are diabetic or newly diagnosed diabetics are
reviewed by the diabetes nurse. Fasting blood
sample results – total cholesterol, HDL-C, LDL-C,
triglycerides, glucose and liver function tests are
reviewed with the patient. The patient’s body
mass index (BMI) is assessed (only being done
recently due to an increased number of staff at
the Cardiac Rehabilitation Unit), a dietary history
is taken and appropriate dietary advice is formulated
as Hooper (2001) claimed that more
lives are saved by providing evidence-based dietary
information to all and discussed with the
patient with emphasis on keeping the advice
practical and relevant to each individual. This is
consistent with Hooper’s (2001) recommendation,
that is, using the best evidence in terms of patient
preference and the dietitians’ own clinical
expertise to formulate a dietary advice agreeable
to both parties. Patients are followed up regularly
by their general practitioners or practice
nurse after they have completed the cardiac
rehabilitation programme.
At the time this study was carried out, a patient
would need to attend the once-a-week sessions
over 6 weeks in order to be considered to have
completed the cardiac rehabilitation programme.
In order to adhere to the National Service
Framework guidelines and also due to an increase
in the number of staff at the Cardiac Rehabilitation
Unit, the sessions are now carried out twice a
week over 4 weeks. Cardiac rehabilitation which
aims to assist the recovery of patients post-myocardial
infarction, angina, post-coronary bypass
surgery and lately, post-angioplasty as well as
30 J. Leong et al.
post-implantable cardiovecter-defibrillator device,
involves a structured programme of medical advice,
behavioural risk factor management, for
example, smoking cessation and weight management,
exercise and psychological support.
Data analysis
The SPSS 11.0 statistical package was used to
analyze the data. Descriptive statistics were calculated
with all study’s variables. Spearman correlations
were calculated between the adherence
items and all other variables. Regression analysis
was used with variables showing a good correlation
with the dependent variable (adherence
items) in order to be able to make predictions as
to who is more likely to be nonadherent. Subgroup
analysis was also used to assess the profile
of nonadherent subjects using Mann–Whitney
tests.
Findings
Sociodemographic and clinical details
One of the criteria for inclusion in the study was
that patients must have attended at least five out
of the six scheduled cardiac rehabilitation sessions.
Out of the 792 patients who registered with the
Cardiac Rehabilitation Unit of the study hospital
between January 2001 to May 2002, only 89 patients
fulfilled this criterion. Four patients died
while investigators were awaiting for the research
proposal to be approved by the ethics committee.
The response rate was 61.2% as 52 patients out of
85 returned the questionnaires.
As can be seen in Table 1, the sample was
predominantly men (n ¼ 42, 80.8%). The respondents
had a mean age of 65.52 years
(SD¼10.88). Seventeen (32.7%) respondents were
still working (5 white-collar workers and 12 bluecollar
workers). Twenty-two (42.3%) respondents
were retired (8 white-collar workers and 14 bluecollar
workers). Information in relation to the
respondents’ ethnicity, level of education and
socio-economic status were not included in the
patients’ records. Twenty-two (42.3%) respondents
received thrombolysis out of which 17
(32.7%) were given Streptokinase and 5 (9.6%)
Reteplase. The majority of participants (n ¼ 42,
80.8%) had a medical history prior to the coronary
event. Thirty-seven (71.2%) respondents
were ex-smokers (those who had smoked precoronary
event). In the case of alcohol intake,
more than half of the respondents (n ¼ 33,
63.5%) were still consuming alcohol. Only 1
(1.9%) respondent totally abstained from alcohol
intake. Fourteen (26.9%) respondents reported
never drinking alcohol.
Patients’ self-reported adherence
More subjects adhered to a healthy diet (n ¼ 20,
38.5%), physical activity (n ¼ 17, 32.7%) and
smoking cessation (n ¼ 14, 26.9%) compared to
other behaviours (Table 2). All subjects reported
that they adhered to taking prescribed medication
as directed.
Table 1 Sociodemographic and clinical characterist
of the sample
N %
Gender
Male 42 80.8
Female 10 19.2
Religion
Christian 44 84.6
None 4 7.7
No response 4 7.7
Occupation
White-collar worker 5 9.6
Ex-white collar worker 8 15.4
Blue-collar worker 13 25.0
Ex-blue collar worker 12 23.1
No response 14 26.9
Thrombolysis
Yes 22 42.3
No 30 57.7
Type of thrombolysis
Streptokinase 17 32.7
Reteplase 5 9.6
Not given thrombolysis 30 57.7
Past medical history
Yes 42 80.8
No 10 19.2
Smoking habit
Non-smoker 15 28.8
Ex-smoker 37 71.2
Alcohol intake
Weekly 20 38.5
Occasionally 13 25.0
Stopped 1 1.9
Never 14 26.9
No response 4 7.7
Adherence of health recommendations 31
Anxiety and depression
The majority of the respondents (n ¼ 38, 73.2%)
were found to be anxiety-free (Table 3). Thirteen
(24.7%) respondents presented with symptoms of
anxiety. Similarly, the majority of the respondents
(n ¼ 41, 78.9%) were found to be depression-free.
Ten (19.1%) respondents presented with symptoms
of depression.
Health beliefs
The scores for the barriers subscale ranged from 11
to 39 with a mean score 17.45 (SD¼5.93). The
scores for self-efficacy subscale ranged from 19 to
47 with a mean score of 35.31 (SD¼5.47). The
scores for health motivation subscale ranged from
13 to 46 and the mean score was 38.04 (SD¼6.24).
Health locus of control
The mean score for internal health locus of control
was 22.25 (SD¼5.62, range¼9–36). The mean
score for health locus of control related to chance
was 18.94 (SD¼6.36, range¼6–34). Finally, the
mean score for health locus of control (powerful
others) was 24.57 (SD¼4.25, range¼16–36).
Correlations
Few significant correlations were observed between
the adherence items and all other study
variables. Adherence to a healthy diet was strongly
correlated with the extent family members encouraged
patients to follow health recommendations
(rs ¼ 0:50; P < 0:001) and older age (rs ¼
0:31; P < 0:05). More frequent adherence to advice
related to social activity was associated with
lower levels of depression (rs ¼ 0:45; P < 0:01).
Higher adherence with smoking cessation was related
with higher levels of self-efficacy (rs ¼ 0:32;
P < 0:05). Finally, higher adherence levels with
physical activity was associated with lower depression
(rs ¼ 0:28; P < 0:05), male gender (rs ¼
0:30; P < 0:05), past medical history (rs ¼ 0:31;
P < 0:05) and higher level of health motivation
(rs ¼ 0:41; P < 0:05).
Table 3 Prevalence of anxiety and depression in the
study population
Frequency Percentage Mean SD
Anxiety 6.31 3.99
Normal 38 73.2
Mild 6 11.4
Moderate 5 9.5
Severe 2 3.8
Depression 4.26 3.55
Normal 41 78.9
Mild 7 13.4
Moderate 1 1.9
Severe 2 3.8
Table 2 Descriptive statistics of the adherence
items
N % Mean SD
Taking prescribed
medication
4.00 0
All the time 51 98.1
Missing 1 1.9
Healthy diet 3.15 0.83
None of the time 2 3.8
Some of the time 8 15.4
Often 22 42.3
All the time 20 38.5
Weight loss 1.53 1.32
Not applicable 15 28.8
None of the time 10 19.2
Some of the time 11 21.2
Often 9 17.3
All the time 4 7.7
Missing 3 5.8
Physical activity 2.86 1.06
Not applicable 1 1.9
None of the time 5 9.6
Some of the time 11 21.2
Often 17 32.7
All the time 17 32.7
Missing 1 1.9
Social activity 2.49 1.00
Not applicable 1 1.9
None of the time 6 11.5
Some of the time 19 36.5
Often 14 26.9
All the time 9 17.3
Missing 3 5.8
Smoking cessation 1.31 1.76
Not applicable 29 55.8
None of the time 6 11.5
Some of the time 1 1.9
Often 1 1.9
All the time 14 26.9
Missing 1 1.9
Alcohol use 1.65 1.34
Not applicable 14 26.9
None of the time 8 15.4
Some of the time 20 38.5
Often 2 3.8
All the time 8 15.4
32 J. Leong et al.
Having identified some significant associations,
subgroup analyses were carried out. The grouping
variables that were used were being anxious (using
the median score), receiving or not thrombolysis,
past medical history, being depressed (using the
median score) and gender. Only adherence with
physical activity was significantly higher in those
with past medical history (P ¼ 0:03) and males
(P ¼ 0:035), and adherence with social activity
advice with lower levels of depression (P < 0:001).
No other significant differences were observed.
A linear regression analysis was used to describe
which study variables were explanatory of adherence
in the current sample. The variables used as
dependent variables were adherence with healthy
diet, weight loss, physical activity and social activity.
The variables that were used as independent
variables were the extent of encouragement by
family members to follow health recommendations,
barriers, self-efficacy, health motivation, health
locus of control (internal), health locus of control
(chance), health locus of control (powerful others),
past medical history, anxiety, depression and gender.
The ratio of subjects to variables was almost
5:1. In adherence with healthy diet, the model explained
38% of the variance and the only predictor
variable was the extent of encouragement by family
members to follow health recommendations (Table
4). In adherence with weight loss, the model explained
16% of the variance and the only explanatory
variable was the health locus of control
(powerful others). In adherence with physical activity,
the model explained 37% of the variance and
the explanatory variables included past medical
history, anxiety and health locus of control (internal).
Finally, in relation to adherence with social
activity, the model explained 41% of the variance
and the explanatory variables were depression,
gender and health locus of control (internal).
Discussion
Adherence to taking medication
The most surprising finding was that almost all
(98.1%) of the respondents adhered to taking prescribed
medication. This is in contrast with many
studies, including clinical trials involving myocardial
infarction survivors, which have reported that
patients do not adhere well to taking prescribed
medication (Glynn et al., 1994). Even when clinical
trials reported adherence rates that may have
overestimated true levels of adherence, there was
still no 100 per cent adherence to taking prescribed
medication. As such, this finding is doubtful as it
may have been related to the self-report used,
where subjects responded based on desirable rather
than actual behaviours. Therefore, to minimize
measurement error in the analyses of
adherence in the future, validity of self-reports
pertaining to taking prescribed medication could
best be supported by blood serum levels.
Anxiety
Symptoms of anxiety were found in 24.7% of the
respondents of this study with 3.8% experiencing
severe anxiety. This indicates that the majority of
the respondents were anxiety-free. This finding is in
contrast with Harvik and Maeland (1990) who reported
that anxiety is a frequent problem that can
persist beyond the hospital period. A possible explanation
for this finding may be that the scale was
not sensitive enough in this cardiological context.
When anxiety is assessed in the presence of physical
disease, some loss of sensitivity is possible as most
scales include several physical symptoms. The
Hospital Anxiety and Depression Scale, however,
Table 4 Predictor variables in the adherence items
Adherence with Predictor variable R2 Beta coefficient P value
Healthy diet Extent of encouragement by family
members to follow health
recommendations
0.38 0.61 <0.001
Weight loss Health locus of control
(powerful others)
0.16 0.40 0.024
Physical activity Past medical history 0.35
Anxiety )0.39
Health locus of control (internal) 0.37 0.32 0.037
Social activity Depression )0.44
Gender 0.36
Health locus of control (internal) 0.41 0.31 0.039
Adherence of health recommendations 33
does not include physical symptoms making it appropriate
measure in clinically ill patients. Considering
the high percentage of respondents with past
medical history, this may further explain the low
anxiety level found in this study. Anxiety was not
associated with any of the adherence variables
(only partially with physical activity), confirming
earlier reports (i.e. Conn et al., 1992), although
controversy about the role of anxiety still exists.
Depression
Symptoms of depression were found in 19.1% of the
respondents of this study with 3.8% experiencing
severe depression. This indicates that the majority
of the respondents were depression-free. This
finding is also in agreement with that of Frasure-
Smith et al. (1995) who reported that depression is
common among patients recovering from myocardial
infarction.
Adherence
A wide range of baseline demographic, behavioural
and clinical variables predicted adherence among
post-myocardial infarction patients. For instance,
it is possible that patients who are depressed are
likely to be poorer adherers. On the other hand,
patients who are on medication due to other illnesses
may be better adherers because they have
already accepted the fact that they have to be on
long-term medication which could then explain the
high adherence rate of 98.1% to taking prescribed
medication among the respondents. The therapeutic
regimen itself as well as social and other
factors may result in the differences in adherence.
While the benefits of therapy may improve adherence,
any adverse effects may reduce adherence.
According to the Woscops (1997), poor adherence
may be directly associated with an end-point itself
in the sense that the deteriorating condition of the
patient prior to the occurrence of an end-point
may lead to poor adherence.
In this study group there was a higher frequency
of respondents adhering to healthy diet as compared
with other adherence items such as physical
activity, smoking cessation, weight loss, social
activity and alcohol use. The higher frequency of
adhering to healthy diet is surprising given that
past studies by Barnes and Terry (1991), Wright
(1994), Lloyd et al. (1995) and Koikkalainen et al.
(1996) who have found that nonadherence to diet
recommendations by the majority of patients was
mostly related to their dislike of the taste of the
cardiac diet. The high frequency of respondents
adhering to physical activity is also surprising as
Andrew et al. (1981) found nonadherence with the
exercise component of cardiac rehabilitation to be
a problem due to the extended period of exercise
maintenance that is required before benefits are
achieved.
This study also showed that adhering to physical
activity was associated with health motivation and
adhering to smoking cessation was associated with
self-efficacy. According to Bandura (1977), selfefficacy
or expectancy about the competence to
make changes successfully might be reflected in a
positive correlation, as in the findings of this study,
between cues to exercise in the health belief
model and adherence with health behaviour recommendations.
In support of this theory, Rosenstock
et al. (1988) suggested that self-efficacy
should be included in the health belief model not
only as an explanatory variable but also as one that
may be manipulated usefully. This is because it is
not yet clear whether health beliefs result in specific
health behaviours or whether health behaviours
result in specific health beliefs. The relatively
small proportions of behaviour explained by the
health belief model in this study could be related
to the inability of subjects to interpret the effects
of “perceived severity of disease threat”; the fact
that “cues to action” do not necessarily lead to
behaviour change; the fact that the assumption of
a directive component of “general health motivation”
may be incorrect; the fact that the model is
health-oriented, ignoring nonhealth factors and
the fact that the relationship between health beliefs
and health decisions is not clear (Leventhal
et al., 1980; Rosenstock et al., 1988). Further, the
influence of health locus of control (internal and
powerful other) can explain partially the variance
in some of the adherence issues and its role in
education programmes or identifying patients at
risk for nonadherence is important.
It was also found that 37.5% of the total variation
in adherence to healthy diet is accounted for
by its linear relationship with the extent that
family members encourage the patient to follow
medical recommendations. It is known that adherence
to the prescribed dietary treatment for
cardiac disease is a universal problem. There have
been very few studies on adherence to multiple
restrictions diet, such as the cardiac diet which
restricts fat, cholesterol and sodium. Factors affecting
patients’ adherence to the cardiac diet is
probably the significant relationship between attitudes
and food behaviours. Attitudes toward therapeutic
diets may be very important in encouraging
patients’ adherence with their diet. Compatibility
of the diet with the patient’s values and felt needs
34 J. Leong et al.
may be increased by involving friends, health care
providers and especially the patient’s family in
supporting the patient’s dietary changes. This
finding is consistent with Thomson (1999) who
agreed that spouse or partner support can improve
adherence to rehabilitation. Since there is evidence
that involvement of family in the rehabilitation
process is a critical factor in its
effectiveness, future cardiac rehabilitation programmes
should include the patient’s family as
much as possible. In view of this, health care professionals
may wish to foster partnership support as
much as possible. This, according to Coats et al.
(1995), could be done by, for example, drawing up
an educational programme for both partners and
participants.
Change of health habits and ensuing health gains
may take longer than the duration of a planned
cardiac rehabilitation programme (Bowman et al.,
1998). Takeda et al. (1996) reported that an increase
in high-density lipoprotein may only be evident
two years after embarking on a new exercise
regime. Schuler et al. (1992) reported that weight
loss, blood fat changes and regression of coronary
artery disease may only be evident after 12 months
following commencement of cardiac rehabilitation.
Therefore, continuity of contact is important
for adherence. Besides the patient’s family members,
health care professionals are able to provide
continuity of support to the patient. Bowman et al.
(1998) emphasized that continued support is important
when damaging health habits are being
changed.
Educational counseling is also important and
popular among patients (Campbell et al., 1994) in
ensuring good adherence. However, the hospital is
probably not the best environment for education to
have a long-term impact as information offered
may be badly organized and delivered (Murray,
1989). Both patients and their families experience
significant distress during the hospital stay (Hilbert,
1993). This can result in information given
being forgotten (Orzeck and Staniloff, 1987). The
researchers found this to be true as certain respondents
of the current study stated that they do
not adhere to certain components of the therapeutic
regimen as they do not understand it or have
forgotten some of its details. Ley (1988) suggested
that supplementing verbal information with clearly
written educational material is important. Booklets
have been shown to significantly increase knowledge
in cardiac patients (Lindsay et al., 1991).
However, a study by Thompson (1989) systematically
examined the effect of in-hospital intervention
and suggested that a simple programme of
in-hospital couple counselling, provided by a coronary
care nurse can significantly reduce anxiety
and depression in first myocardial infarction patients
and anxiety in their partners. This finding
compares favourably with those of previous inpatient
studies by Gruen (1975), Langosch et al.
(1982) and Oldenburg et al. (1985). Thompson’s
(1989) finding also support Perkins et al. (1986)
study which concluded that there is accumulating
evidence to demonstrate that in-hospital psychological
and educational interventions with first
myocardial infarction patients in the days immediately
post-myocardial infarction favourably influences
psychological outcome. Furthermore, a
prospective evaluation of in-hospital counselling
for first time myocardial infarction men by
Thompson and Meddis (1990) also found that patients
who received in-hospital counselling reported
statistically significantly less anxiety and
depression than those who received routine care
alone and that this effect was sustained for 6
months after discharge from the hospital. Also, in
another study by Johnston et al. (1999) about the
impact on patients and their partners of inpatient
care and extended cardiac counselling and rehabilitation,
it was found that inpatient cardiac
counselling and rehabilitation resulted in more
knowledge, less anxiety, less depression and
greater satisfaction with care in both patients
and partners and in less disability in patients, with
effects enduring to 1 year.
The convenience and small sample size are major
limitations in this study. Inclusion of some
open-ended questions in future research may give a
more accurate picture of why nonadherence is
taking place. The representativeness of the sample,
deriving from a single centre is also affected.
Furthermore, data on social deprivation or socioeconomic
status would have been useful, but such
data is not regularly collected by the hospital’s
Data Quality Office and the ethics committee did
not want to intrude on such a sensitive issue. The
mean age of the sample was older compared to
that reported by other researchers studying myocardial
infarction survivors. This may be because
researchers in the past have chosen to exclude
older people in their studies. Women were underrepresented
in the study and future research
should focus on adherence in women, as different
factors may contribute to nonadherence in this
group and different gender-specific interventions
may be required in cardiac rehabilitation programmes.
The women were also found to be older
than most men in the group. A high percentage of
subjects with past medical history was also found.
A possible explanation for this could be that previous
researchers studying myocardial infarction
Adherence of health recommendations 35
survivors have chosen to exclude patients with past
medical history, chronic illnesses or multiple
health problems to make associations between
study variables more clear. These differences
compared to past studies need to be considered
since women, subjects with no past medical history
and those in the lower age group have not been
fairly represented. Another limitation of the study
may be the fact that we did not assess the number
of medication taken by each patient. This data was
not available, as the full information are only with
the patients’ general practitioner, but we know
that 20 out of 52 patients have also other medical
conditions for which they take medication, such as
asthma, arthritis, diabetes and peptic ulcers.
However, in future studies, accurate information
on this variable is essential in estimating percentages
of nonadherence to medication.
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38 J. Leong et al.

Patient-specific factors relating to medication adherence in a
post-percutaneous coronary intervention cohort
Gordon F. Rushwortha, Scott Cunninghamb, Alasdair Mortc, Ian Ruddd and Stephen J. Leslied,e
aHighland Clinical Research Facility, Centre for Health Science, Inverness, bSchool of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen,
cCentre for Rural Health, University of Aberdeen, dPharmacy Department, Raigmore Hospital, Inverness and eHighland Campus, University of Stirling,
Inverness, UK
Keywords
aspirin; medication adherence; PCI;
percutaneous coronary intervention
Correspondence
Mr Gordon Rushworth, Advanced Pharmacist
Clinical Research, Highland Clinical Research
Facility, Centre for Health Science, Old Perth
Road, Inverness IV2 3JH, UK.
E-mail: gordon.rushworth@nhs.net
Received February 9, 2011
Accepted November 18, 2011
doi: 10.1111/j.2042-7174.2011.00185.x
Abstract
Objective To explore the association between medication adherence and qualitatively
characterised patient-specific themes relating to medication adherence in
patients following percutaneous coronary intervention (PCI).
Methods Data-collection questionnaires and qualitative topic guides were piloted
in two patients.A validated questionnaire generated an adherence score for a convenience
sample of 20 patients within 7 days of PCI. Semi-structured qualitative interviews
were subsequently carried out with all patients to explore patient-specific
themes relating to measured medication adherence.
Key findings Fourteen out of 20 patients (70%) had scores indicative of good
adherence.Key factors associated with good adherence included having a good relationship
with the doctor, having an understanding of the condition, knowledge of
the indications and consequences of non-adherence, perceived health benefits and
medications eliciting tangible symptom control. There were misconceptions of
concern regarding adverse drug reactions and the importance of aspirin, both of
which had a negative effect on adherence. The role of the community pharmacist
was sometimes, although not always, misunderstood.
Conclusion This study suggests there is an association between patients’ beliefs,
knowledge, understanding and misconceptions about medication and their adherence
in a post-PCI cohort. To optimise medication adherence it is vital for prescribers
to remain patient-focused and cognisant of patient-specific themes relating to
medication adherence.
Introduction
The concept of patient adherence to medication is unique
from compliance. Adherence avoids some of the negative
connotations that the term‘compliance’ has been taintedwith
over the last two millennia of traditional physician-to-patient
consultations. Compliance is a simplistic term which relates
to the degree to which the patient follows the direct instructions
of the prescriber.Moreover, with the idea of adherence
comes an additional concept related to understanding why
patients are adherent, or otherwise. In turn, this enables differentiation
between patients who have purposefully chosen
not to take a medication (intentional non-adherence) and
those that have not been able to take their medication due to
practical reasons (unintentional non-adherence).[1–3] The key
subtle difference between the two terms stems fromthe ability
to understand why patients are not taking their prescribed
medication. The benefits of this stratification are revealed
when considering health-seeking behaviour.Recent guidance
from the UK National Institute forHealth and Clinical Excellence
(NICE) has reiterated the importance of determining
the rationale for a patient’s decision to take, or not take, medication.[
4] This reasoning can then be explored to find amutual
solution to potential adherence problems.
In patients prescribed statins, non-adherence was influenced
by patients’ own beliefs about their medication and the
perceived benefit derived from them.[5] Beliefs aboutmedication
have been identified as being a predictor of adherence.[6]
A number of studies have defined the benefit(s) patients
perceive that they will gain from their medication.[5,7–10]
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International Journal of
Pharmacy Practice
International Journal of Pharmacy Practice 2012, 20, pp. 226–237
Research Paper
© 2012 The Authors. IJPP © 2012 Royal Pharmaceutical Society International Journal of Pharmacy Practice 2012, 20, pp. 226–237
Therefore, in order to improve medication adherence it is
essential to understand more about patients’ beliefs regarding
their medication.[11] There is evidence that adherence may be
enhanced by improving patient education and counselling.[12]
In taking this approach, healthcare professionals should
be cognisant of the level of understanding patients may be
able to achieve.[9] Views regarding the benefits of medication
should be discussed during the consultation, and at the point
of prescribing between the prescriber and patient.[10] Patients
will be able to appreciate the benefits of their medication
if they have better understanding, especially when they are
required to take them for long periods of time.[9,13] Notably,
misconceptions surrounding disease states are associated
with poorer physical health;[14] in turn, a poor understanding
of the disease increases the likelihood that the patient will not
understand the benefits of taking their medication.[12]
Following percutaneous coronary intervention (PCI)
patients fall under the auspices of being treated for a longterm
condition – coronary heart disease – and therefore
require medication. PCI can be done either electively or after
an acute event.According toWorldHealth Organization data,
the average adherence rate for patients on medication for
long-termconditions is 50%.[15]
One retrospective study[16] in patients prescribed antiplatelet
therapy (clopidogrel) following an acute coronary
syndrome (ACS) who had been treated with either a bare
metal stent (BMS) or a drug-eluting stent (DES) reported
higher mortality in patients who discontinued clopidogrel
early; up to 18 months post-ACS. Furthermore, the increase
in adverse events appears highest in the first 90 days after
stopping the thienopyridine antiplatelet clopidogrel in
both medically and PCI-treated ACS patients (incidence
rate ratios 1.98 and 1.82 respectively).[17] This study did not
explore the reasons why patients stopped taking thienopyridine
drug therapy. Even assuming that adherence to dual
antiplatelet post-PCI medication is good, stent thrombosis
occurs in 0.5–2% of elective and up to 6% of ACS patients
who are given a stent.[18] Thus the risk of a cardiovascular
event due to stent thrombosis increases with increasing
non-adherence.
In a further study investigating the prevalence and predictors
of thienopyridine antiplatelet discontinuation postmyocardial
infarction (MI) in patients treated with BMS,
almost one in seven patients discontinued thienopyridine by
day 30.[19] This was associated with a significantly higher
increase in mortality over the next 11 months (7.5 compared
with 0.7%, P<0.0001). Those who discontinued were less
educated, not married,had previous co-morbidities andwere
generally older. What the study did not illustrate, beyond
interpretation of demographic data, were the reasons why
individual patients had stopped their medication.However, it
does allowfor hypotheses to be drawn fromthe results, which
can be explored further using qualitative techniques.
The effect of medication cost in relation to adherence has
been studied by Ko et al.[20] in 10 000 patients, all of whom
were above the age of 65 and had received either BMS or
DES as PCI in Canada. Thienopyridine antiplatelet therapy
was given to patients at low cost. This study found that nonadherence
was highest in the patients who had to pay the
most for their prescription. The group who received free
medication were almost 70% more likely to order prescriptions,
thus implying a prohibitive effect of healthcare charges
and supporting the argument that patients who have to pay
for medication are less likely to access it. Non-adherence
increased the risk of mortality. The investigators also found
that patient adherence decreased with increasing time after
the index event, suggesting that a degree of ambivalence
manifests with time.
The effect of adherence to statin therapy has also been
investigated post-PCI.[21] The relative risk reduction for those
on statin post-PCI was reported as 22% in the original trial.
After analysis and adjusting for non-compliance, the relative
risk reduction for major cardiac events was 32%, with the
additional 10% relative risk reduction being due purely to
good adherence tomedication.
Previous research has quantitatively characterised some
aspects of medication adherence post-PCI. However, there
has not been a detailed exploration of the patient-specific
factors relating to such adherence. There is therefore a need
to address this deficiency. The aim of this study was firstly
to quantify the current level of medication adherence using a
validated scale, and then to qualitatively explore the association
between the measured adherence and the influencing
factors.
Methods
Settings and subjects
A convenience sample of 20 patients were recruited to the
study. All patients had undergone PCI in the previous 7 days
and had completed phase I cardiac rehabilitation. Inclusion
criteria included being on three or more cardiacmedications
(including any of the following: antiplatelets, statins/fibrate/
ezetimibe, b-blockers, angiotensin-converting enzyme
inhibitors, angiotensin 2 receptor blockers, nitrates, nicorandil,
calcium-channel blockers, antiarrhythmics), age
of 18 year or more, fluent in English and being able to give
informed consent. Patients were excluded from the study if
they had cognitive impairment, had known alcohol or illicit
drug use, had a physical or psychological disability inhibiting
communication, were using a compliance aid (i.e. dosette
box) or resided in a nursing, residential or care home.
The sample size for this project was determined by data
saturation caused by repeated thematic recurrence in the
Gordon F. Rushworth et al. 227
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qualitative semi-structured interviews. Evidence indicated
that up to 25 patients would be required to achieve this.[22,23]
Ethics approval
Full ethical approval was granted by the North of Scotland
Research Ethics Service on the 22nd March 2010. Patients
were given an information sheet about the study by cardiology
staff who would normally be involved in the care of PCI
patients.After a minimum of 24 h to reflect on that information,
if they wished to participate in the study a meeting was
set up with a researcher (GFR) where further information
about the study was given and written informed consent
taken before participation in the study.
Pilot study and validation
A pilot study (two patients) was conducted in the penultimate
week of April 2010. Both patients met the inclusion and
avoided the exclusion criteria for the study. The pilot study
was required to check that the methods, procedures and
documentation to be used in the study were acceptable to the
research participants, and secondly that the methods used
would yield data required to answer the research question.
Data collection and analysis
Completion of consent forms, questionnaires and interviews
was conducted by a single researcher (GFR) at Raigmore
Hospital, Inverness.
Demographic data
Demographic data were collected regarding the medical,
social, financial and educational background of each participant;
a full medication history was also taken. This enabled
descriptive statistics to be used to characterise the sample.
Adherence score
A review of published adherence screening tools was undertaken
(Table 1[24–37]). This identified the Tool for Adherence
Behaviour Screening (TABS)[35] as the most appropriate
questionnaire to provide an accurate, fast and reliable indication
of medication adherence in patients with chronic conditions.
The reliability and internal consistency, as well as the
construct, criterion and incremental validity of TABS, were
proven for use in chronic conditions.[35] The completion
of TABS involves the patient answering two sets of four
questions using a five-point Likert scale. Answers from the
first set give an adherence behaviour score (ABS) and answers
from the second set give a non-adherence behaviour score
(NABS). ABS of less than 19 out of 20 denote a lack of adherence
behaviour whereas NABS of more than eight out of
20 can be defined as non-adherence behaviour.[35] Low scores
for ABS are suggestive of intentional non-adherence whereas
low scores for question 5 (NABS) suggest unintentional nonadherence.
It should be noted that although TABS comprises
ABS and NABS, cumulative totals of the scores are unable to
be given due to the inverse relationship between the scoring
for ABS andNABS. Descriptive statistics were used to characterise
the sample.
Qualitative semi-structured interview
A semi-structured interview was selected as the most appropriate
methodology to explore patients’ ideas, concerns and
expectations about adherence tomedication. Interviews were
conducted by the corresponding author over a 7-week period
from May 2010. The topic guide for semi-structured interviews
was adapted from another study of medication adherence
in patients with chronic illness.[22] This was reviewed
for appropriateness by the team prior to use. All interviews
were digitally recorded before being transcribed by cardiology
secretarial staff. Once the interviews were transcribed the
accuracy of the transcriptions was scrutinised by the corresponding
author. Patient confidentiality was maintained by
omitting all names and identifiers, and patient approval for
the use of direct quotations was obtained. Once the qualitative
data had been transcribed the transcripts were loaded
into computer-assisted qualitative data analysis software
(Atlas.ti version 6.0.1; Atlas.ti GmbH, Berlin, Germany)
which expedited analysis and enhanced ‘closeness’ with the
data. A thematic framework was developed to code the transcripts.
The original coding framework was agreed upon by
GFR and SJL. GFR completed the coding and SJL verified the
accuracy of each applied code on all transcripts. Initially there
was a process of familiarisation by listening/re-listening
to the recorded interviews while reading/re-reading the
transcripts, which allowed immersion in the data. A process
of ‘coding’ was applied to the transcripts and these codes
allowed for themes to be identified. The construction of the
initial thematic framework was guided by the research aims
and objectives and questions introduced to participants from
the topic guides.However, the framework analysis could also
be used to identify emergent themes expressed during the
interviews, offering a unique flexibility to realise themes from
outwith the topic guide. Contextual meaning for each quote
and code were then indexed before being displayed in a
process called charting. Finally, associations between codes
and themes were explored during mapping and interpretation.
Relevant quotes supporting the framework could then
be displayed. Identifiers for individual patients followed each
quote and were given as the patient number, the paragraph
number in the transcript, sex, age and TABS scores represented
as the ABS and NABS.A framework analysis provided
228 Medication adherence post-PCI
© 2012 The Authors. IJPP © 2012 Royal Pharmaceutical Society International Journal of Pharmacy Practice 2012, 20, pp. 226–237
a robust technique for the analysis of qualitative data as it
facilitates rigorous and transparent data management.[38,39]
This analysis was completed in parallelwith recruitment until
data saturation was determined.
Methodological rigour
The rationale for choosing TABS has already been discussed.
The TABS questionnaire was validated in another chroniccondition
cohort, chronic obstructive pulmonary disease,
and was shown to be a reliable score for measuring adherence
in a population with chronic disease.[35]
Results
Twenty patients (15 male, 5 female) met the study’s inclusion/
exclusion criteria and consented to take part – there were no
refusals to participate in this research. This sample size
achieved data saturation: this was the stage at which no new
themes were generated. Eight additional interviews were
Table 1 Review of suitability of published adherence scores
Name of scale Acronym Disease state Reliability Validity Comments
Beliefs about Compliance
Scale[24]
BMCS Heart failure Yes Yes Disease-specific questions
Dutch Heart Failure
Knowledge Scale[25]
DHFKS Heart failure Yes Yes Useful for understanding the effect
of education or counselling.
Medication Adherence
Scale[26]
MAS Heart failure Yes Yes Only one question about
adherence. It was taken from
another scale. Adherence was
determined electronically.
Compliance of
Hypertensive Patients[27]
CHPS Hypertension Yes Yes Scale not presented in the paper.
Not solely a medication scale.
Medication Adherence
Self-Efficacy Scale[28]
MASES Hypertension (in
African-American
patients)
Yes Yes More about barriers to medication
adherence. Discusses cost of
medication. Long: 43 questions.
Adherence self report
tool[29]
– Hypertension No No (in those with
low adherence)
Potentially useful due to being only
six questions long, but not tested
sufficiently to demonstrate
validity and reliability.
Brief Medication
Questionnaire[30]
BMQ Patients on
angiotensin-converting
enzyme inhibitors
Not discussed
in paper
Yes The scale does not appear to have
been published in its entirety.
Maastricht Utrecht
Adherence in
Hypertension
Questionnaire[31]
MUAH-Q Hypertension Not discussed
in paper
Needs further
testing
Focused on blood pressure
Adherence Self-Reported
Questionnaire[32]
ASRQ Hypertension Yes Yes Poor prediction of non-adherent
patients
Medication Adherence
Rating Scale[33]
MARS Mental health patients Yes Yes Uses 10 questions which are
interesting. Could potentially be
applied to a cardiac cohort.
Brief Evaluation of
Medication Influences
and Beliefs[34]
BEMIB Schizophrenia Yes Yes Disease-specific questions
Beliefs and Behaviour
Questionnaire including
Tool for Adherence
Behaviour Screening[35]
BBQ and TABS Chronic respiratory
conditions (designed
to be applicable to
other chronic disease
states too)
Yes Yes The entire BBQ is 30 questions.
However, the behaviour section
alone can be used to determine
adherence. Both have reliability
and validity. Eight questions.
Medication Adherence
Measure[36]
Morisky Hypertension Yes Yes Four questions, easy to administer.
8-Item Medication
Adherence Measure[37]
8-item Morisky Hypertension Yes Yes Eight questions, easy to administer.
Reliability and validity have been
proven.
Gordon F. Rushworth et al. 229
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conducted with no new themes emerging to define data
saturation.
Demographic data
Data was wide ranging with regard to age, height and weight
of the participants. Only five patients (25%) were found to be
of a healthy body mass index (20–25 kg/m2); seven (35%)
were clinically obese with a body mass index of more than
30 kg/m2. Male patients comprised 75% of the cohort.
The majority of the patients were employed (60%) (Tables 2
and 3).
TABS data
Patients were colour-coded according to their TABS scores
(Figure 1). Six patients (30%) (patient numbers 001, 004,
005, 014, 017 and 019) were found to have low ABS (<19/20)
(Figure 2). Of those six, only two (patients 014 and 019) were
also found to have high NABS (>8/20).
The median ABS for this cohort was 19/20, whereas the
median NABS was 7/20; both scores were suggestive of good
adherence within the cohort (Table 4). The high value of the
median ABS and low value of the median NABS indicated a
desire in most patients to take their medication.
The value of Pearson’s r exhibited no correlation between
the NABS and the ABS. The clustering of patients in the box
on the top left of Figure 2 indicated that 70% of patients
scored high for ABS and low for NABS, which is suggestive of
good adherence.
Qualitative interview analysis
The full thematic analysis can be seen in Figure 3. The main
themes that relate to medication adherence can be found in
Figure 4.Most of the themes were positively associated with
increasedmedication adherence.However, the role of adverse
drug reactions (ADRs) had a significant negative effect,
while the community pharmacist role was considered nonsignificant
by the majority of patients.
ADRs
In general, the cohort (especially thosewith lowABS and high
NABS) had a good knowledge of commonly experienced
ADRs due to medication they were prescribed. However,
as 50% of patients with either a low ABS or high NABS
expressed knowledge of ADRs this implies there may be an
association between that knowledge and non-adherence.
When it says in the leaflet that it can cause irreversible
muscle damage and may result in hospitalisation, that’s
enough to focus my mind!
005: (78).Male, 56 years old, ABS 17,NABS 5
I think the b-blockers seem to make me a bit sleepy. I
mean that if I said Iwould phone someone in the evening,
I might be asleep and didn’t phone, that sort of thing.
Other than that it doesn’t hamper me.
004: (5). Female, 59 years old, ABS 18,NABS 8
The importance of the difference between the terms compliance
and adherence is demonstrable when considering the
quotes and TABS scores of patients 004 and 005 above.While
the TABS scores indicate the potential for poor adherence
the nature of that association can be further explored by
considering the reason for the scores. In these instances the
knowledge of ADRs may influence a patient’s decision as to
Table 2 Numerical data summary analysis
Topic
Median
(interquartile range)
Medical conditions 3 (2–5)
Prescribed medications 9 (6.8–10.3)
Doses per day 9 (7.8–13)
Tablets per day 9.5 (6–15.3)
Age (years) 60.5 (55.5–66.3)
Weight (kg) 89.5 (70.8–96.4)
Body mass index (kg/m2) 28.6 (24–33)
Table 3 Categorical data summary analysis
Topic Descriptor
Number
of patients Percentage
Marital status Married 13 65%
Single 4 20%
Widowed 2 10%
Divorced/separated 1 5%
Total 20
Education University 6 30%
College 5 25%
High school 8 40%
Pre-high school 1 5%
Total 20
Annual income
(GB £)
>30 000 5 26%
20–<30 000 3 16%
10–<20 000 5 26%
<10 000 6 32%
Total 19
Employment status Employed 12 60%
Retired 6 30%
Disability/unable 2 10%
Total 20
Ethnicity White Scottish 16 80%
White British, other 4 20%
Total 20
Gender Male 15 75%
Female 5 25%
Total 20
230 Medication adherence post-PCI
© 2012 The Authors. IJPP © 2012 Royal Pharmaceutical Society International Journal of Pharmacy Practice 2012, 20, pp. 226–237
whether they wish to be or can be adherent; that is, intentional
non-adherence as the result of experiencing an ADR.
Indications
Thirteen patients discussed the impact that having an understanding
of the indication has for adherence. These ideas
varied greatly between patients.
After an operation especially [PCI], I think people have
got to understand that certain pills do certain things to the
body that helps them,but if they are a bit wary of pills then
they are not inclined to take them unless it is explained
why they are taking them[and]why they are to take them.
002: (157). Female, 70 years old, ABS 20,NABS 7
Another patient (008)with highABS and lowNABS admitted
to not understanding what his medication was prescribed
for.However, critically, his adherence remained high because
he had rationalised the need for additional medication and
therefore perceived a health benefit with the medication.
I know that these tablets are being prescribed for a reason
and probably the truth is, what each tablet does for the
body, I don’t really know, but obviously I have had to
receive another couple because obviously number 1 for
example doesn’t do what number 2 and 3 does otherwise
I perhaps wouldn’t be on a second or a third, but I do
understand that I have to take that medicine.
008: (17).Male, 54 years old, ABS 19,NABS 7
Relationship with doctor
There was a higher frequency of quotes for this code
than any other. In total 17 patients offered ideas about
the doctor–patient relationship. Of the 17 patients, 16 noted
good relationships with their general practitioner (GP).
Patient 019 (low ABS and high NABS) described a poor
working relationship but was still of the belief that a good
relationship was desirable.
A number of patients were also of the opinion that if a
medication was prescribed for you by a doctor then it should
be taken regardless.
Well to me it is common sense. If the doctor says you need
it then you need it so you should take it.
009: (133).Male, 64 years old, ABS 19,NABS 4
I am just the sort of guy that would take the medicine
anyway I think having had it prescribed, but, I think
it is good to have confidence in your doctor and
believe that he knows what he is doing and has your best
interests at heart and I think that is the case with my
doctor.
012: (77).Male, 79 years old, ABS 20,NABS 4
It’s prescribed by the doctors and that is it you would still
take it.You know you have such faith in the doctors,well I
have, I can’t speak for everyone else but I do.
013: (70). Female, 62 years old, ABS 19,NABS 6
High adherence behaviour,
low non-adherence
behaviour
High adherence
behaviour, high nonadherence
behaviour
Low adherence behaviour,
low non-adherence
behaviour
Low adherence behaviour,
high non-adherence
behaviour
Increasing non-adherence behaviour
Increasing adherence behaviour
Figure 1 Colour coding for Tool for Adherence Behaviour Screening (TABS) scores dependent on behaviour.
Gordon F. Rushworth et al. 231
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Community pharmacist
The results uncovered a lack of understanding of the
role of the pharmacist. Patients did not want to undermine
the stature of the prescriber. There was also a misconception
that for serious ailments pharmacists have no role to
play.
. . . Ihavenever seenthe pharmacist in that role, they sort
of sit behind a shop counter. I know it is a highly trained
profession, sowhy not? Because once they are prescribed, I
have already been to the GP.
020: (238).Male, 52 years old, ABS 19,NABS 7
Not if it was to do with the heart.
014: (182).Male, 65 years old, ABS 16,NABS 9
Aspirin
There would appear to be a view among the cohort that
aspirin holds less importance than othermedication.
. . . if it is something minor like an aspirin or something, I
know I have to take the aspirin formy heart but if I missed
one it wouldn’t bother me so much.
002: (149). Female, 70 years old, ABS 20,NABS 7
012
20
18
16
14
12
10
8
6
4
4 6 8 10 12
Non-adherence behaviour score (NABS)
Pearson’s r
Adherence behaviour score (ABS)
Patient number
14 16 18 20
006
001
005 017
014
019
004
003 013 008;020
Non-adherence is defined as:
ABS < 19/20
NABS > 8/20
–0.353
Lower ABS are associated with intentional
non-adherence
007;016
009
002;010;015
011;018
Figure 2 Patient-specific non-adherence behaviour score (NABS) and adherence behaviour score (ABS). Shades of grey on the graph relate to the
colour coding shown in Figure 1.
232 Medication adherence post-PCI
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Table 4 Tool for Adherence Behaviour Screening (TABS) questions and scoring
Question
Never
= 1,
% (n)
Rarely
= 2,
% (n)
Sometimes
= 3,
% (n)
Often
= 4,
% (n)
Always
= 5,
% (n)
Median score
per question
(interquartile
range)
Median score
for ABS/NABS
(interquartile
range)
Adherence
behaviour
score
1. I have strict routines for using my
medicines.
0 (0) 5 (1) 5 (1) 15 (3) 75 (15) 5 (4.75–5) 19 (18–20)
2. I keep my medications close to where I
need to use them.
0 (0) 0 (0) 5 (1) 10 (2) 85 (17) 5 (5–5)
3. I ensure I have enough medications so I
do not run out.
0 (0) 0 (0) 0 (0) 15 (3) 85 (17) 5 (5–5)
4. I push myself to follow the instructions
of my doctors.
0 (0) 0 (0) 0 (0) 65 (13) 35 (7) 5 (4–5)
Non-adherence
behaviour
score
5. I get confused about my medicines. 50 (10) 45 (9) 5 (1) 0 (0) 0 (0) 1.5 (1-2) 7 (5.75–7.25)
6. I make changes in the recommended
management to suit my lifestyle.
75 (15) 20 (4) 5 (1) 0 (0) 0 (0) 1 (1–1.25)
7. I vary my recommended management
based on how I am feeling.
80 (16) 15 (3) 5 (1) 0 (0) 0 (0) 1 (1–1)
8. I put up with my medical problems
before taking any action.
25 (5) 20 (4) 30 (6) 25 (5) 0 (0) 3 (1.75–3.25)
Medication Misconceptions Patient factors Disease
Symptom
control (10)
Understanding
of condition (6)
Lifestyle (16)
System/routine
(19)
Consequences/
fear (11)
Perceived
benefit/effect
(15)
Barriers (10)
Communication
and information
ADRs (7) Aspirin (8)
Treatment (9)
Disease (3)
Relationship
with doctor (30)
Community
pharmacist (15)
Personalised
care (3)
Information (25)
Interactions (4)
Indications (21)
Importance (16)
Missed doses (6)
Figure 3 Themes presented in families from semi-structured interviews. Numbers in parentheses indicate frequency; ADR, adverse drug reaction.
Gordon F. Rushworth et al. 233
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I understand the aspirin is important but I don’t think in
relation to the other pills it is as essential. But I always
take it and I always make sure I have it.
002: (153). Female, 70 years old, ABS 20,NABS 7
. . . the aspirin in less important because that is general
thinning.
020: (118).Male, 52 years old, ABS 19,NABS 7
System/routine
Overall 13 patients in the cohort reported having a routine or
system for taking their medication. There was a belief among
these patients that having a routine improved their adherence.
I have been taking them for 18 years now so it is just a
routine now. It is part of my lifestyle.
009: (69).Male, 64 years old, ABS 19,NABS 4
One of the main tips that these patients had was that by
keeping medication in the same place (and preferably visible)
this acts as a prompt to takemedication.
I have another pill which I take prior tomy evening meal.
In order not to forget that I also have a whisky before my
evening meal! . . . I never forget thewhisky . . .
012: (21).Male, 79 years old, ABS 20,NABS 4
I forget almost never. Just basically by keeping it in the
same area and doing it at the same time.
003: (57).Male, 65 years old, ABS 19,NABS 5
Consequences/fear
The experience of severe chest pain and the subsequent
knowledge that it was a heart attack acted as a motivating
factor to many.
If you know the consequences well. . . I don’t
want to suffer the consequences of going back in [to
hospital] with a heart attack or something like that.
It probably does frighten you into taking it and don’t
miss it out.
016: (89).Male, 59 years old, ABS 20,NABS 6
Trust or faith in
doctor
Understanding
of indication
and condition
Improvement
in symptom
control
Having a
routine or
system
TABS
scores
Fear of
consequences
of nonadherence
Community
pharmacist
ADRs
Perceived
health benefit
Figure 4 Primary patient-specific themes relating to Tool for Adherence Behaviour Screening (TABS) scores from qualitative interviews. ADR, adverse
drug reaction.
234 Medication adherence post-PCI
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Perceived benefit/effect
I understand that the medicines are going to be good for
me, I understand the importance of keeping a supply and
trying not to miss them, I have only missed the odd one in
the evening when I had missed one, I ignored it.
005: (71).Male, 56 years old, ABS 17,NABS 5
I will continue to take it but if I don’t think it is suiting at
all then I normally put it in the back of the drawer and
forget about it.
019: (21).Male, 56 years old, ABS 17,NABS 11
While patient 005 stated that he understood the importance
of taking his medication he also admitted to missing doses,
questioning the motivation he has to remain adherent.As for
patient 019, his quote demonstrates explicitly intentional
non-adherence. This quote further explains the reasoning
behind the low ABS and high NABS.
Understanding of condition
Having an understanding of your heart condition and the
drugs used to treat it was highlighted as a fundamental principle.
Once a patient has this knowledge it contributes to their
adherence. This process was a key step for patient 020 in
establishing amethod for ensuring no furtherMIs.
. . . because understanding the medication is part of
understanding the condition, I am not just understanding
what happened to me but also trying to make sure
that it doesn’t happen again, so it is important to understand,
for the patient, for me to understand why I am on
certain drugs.
020: (34).Male, 52 years old, ABS 19,NABS 7
Patients with low ABS or high NABS
One prominent issue noted in patients with low ABS or
high NABS was around ADRs. Four out of the six patients
mentioned ADRs during the interview. Importantly they
were able to discuss the particular types of ADR they might
expect from their prescribed medication. Low ABS or high
NABS was not associated with baseline characteristics such as
education completed, employment and income.
Discussion
Summary of main findings
High ABS and low NABS, suggestive of good adherence,were
found in 70% of the patients in this cohort. Figure 4 depicts
themes derived from patient interviews which impacted on
the scores expressed. Each theme is dependent on individual
patients’ specific beliefs, knowledge and understanding
of their own condition. However, attaining high ABS or low
NABS is not reliant on expression of all the themes. If patients
believed strongly in only one or two themes this could be
enough to result in a good score.
On the periphery of these themes, and not as central to
medication adherence and certainly not as widespread, are
other themes such as information sources, understanding of
medication and help from a community pharmacist.
There was a misconception among some post-PCI patients
about the potential benefits of taking aspirin. Perhaps the
ubiquitous nature of aspirin prescribingmay have led to some
misconceptions about the efficacy of the medication. This is
especially concerning when considering the critical role of
aspirin in the prevention of post-PCI complications including
stent thrombosis.It seemed as though aspirin was not thought
by some patients to be as important as othermedications.
Limitations of this research
All 20 patients were recruited into the study within 7 days
of undergoing PCI. The close chronological proximity of
this study to the procedure and the information given during
phase I cardiac rehabilitation may make patients, at the time
of recruitment into the study, more inclined to take medication.
The sustainability of this adherence was not investigated
as it was outwith the scope of the research question.
The cohort studied included patients who had undergone
PCI electively or following an acute MI. Whether a patient
had experienced an MI or they were having PCI electively
may have augmented an increase in motivation to takemedication.
Those patients who had experienced an MI spoke
of excruciating pain, as well as fear of subsequent events.
The risk of stent thrombosis to patients from non-adherence
with post-PCI medication is however the same. Therefore, it
is appropriate to be indiscriminate with the selection of a
post-PCI cohort.
The qualitative results of the study are based on interviews
with patients. It should be noted that quotations are thus
based on accounts of events rather than on specific evidence
of those events. Also, from a reflexive perspective, all participants
in the study knew theywere going to be interviewed by a
pharmacist about their adherence tomedication.Again, these
factors may have influenced the study and the responses for
participants.
Comparison with the findings from
other literature
This was the first study to explore the patient-specific factors
associated with medication adherence in a post-PCI cohort.
However, patient adherence to the antiplatelet drug clopidogrel
has been measured in two studies of post-PCI patients
without characterising the reasons for such adherence. Firstly,
Gordon F. Rushworth et al. 235
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Spertus et al. reported that one in seven post-MI patientswith
a stent stopped clopidogrel by 30 days, resulting in a significant
increase in mortality over the next 11 months from0.7 to
7.5% (P < 0.001).[19] No patients in the cohort studied in this
research overtly stated the opinion that they would cease clopidogrel,
except on the decision of a doctor.Secondly,Ho et al.
reported that discontinuation of clopidogrel increases risk of
mortality in post-ACS patients with a stent from 6.9 to 19.9%
(P < 0.001).[16] The risk of not being adherent with the
post-PCI antiplatelet regimen is evidently potentially lifethreatening.
In light of the discovery in this research, greater
emphasis should be placed on the importance of aspirin, both
by the healthcare professional and for the patient by means of
appropriate education about the risks of death.
The proportion of patients with high ABS and low NABS,
suggestive of good adherence, was considerably higher than
the 50% mean adherence rate for patients on medication for
long-termconditions.[15] The results presented give an insight
into patient-specific themes relating to adherence behaviour
as well as quantifying that behaviour.
Implications for practice
For some patients the role of the community pharmacist
was not well understood. The implementation of new and
advanced pharmaceutical services for patientswith long-term
conditions, like the Chronic Medication Service (CMS) in
Scotland,will increase the profile of the community pharmacist
among other healthcare professionals in the management
of chronic disease states.[40] It remains to be seen what impact
thisnewrole for community pharmacistswill have on increasing
adherence inpatients.However,as this researchhas shown,
it isimperative that patientshaveagoodrelationshipwith their
doctor,or other healthcare provider if this role is devolved.
By delivering personalised care (a tailored approach to
medication prescribing and practice) specific needs of individual
patients can be met.Personalised carewould drawfrom
information, advice, support, feedback and continued education
based on the themes identified in this research to provoke
and invoke adherence. Only then can the prescriber–patient
relationship attain good adherence though concordance. This
involves migration away from the historical paternalistic
prescriber-led consultations to one in which the patient feels
they have a key role to play. Principally, the issue here is one of
prescriber cognisance while prescribing.
Conclusion
The results are suggestive of an association between patients’
beliefs, knowledge, understanding and misconceptions about
medication and their adherence. The nature of such an association
is dependent on themes relating to prescribed medication,
communication and information, disease, individual
patient factors and in particular misconceptions about all the
above.However, the associations between the specific themes
relating to adherence and an individual patient’s adherence
are not uniform. They are instead individual, pertaining
exclusively to each patient. Increasing adherence therefore has
to be tailored to the needs of the individual. Interventions
should draw upon the themes relating to adherence outlined
in this research, before selecting the most appropriate course
to meet the needs of the individual. Essential to the understanding
of the themes required is an understanding of the
patient by the healthcare teamand in particular the prescriber.
Declarations
Conflict of interest
The Author(s) declare(s) that they have no conflicts of interest
to disclose.
Funding
This research was supported by the NHS Highland Research
& Development Committee Endowment Fund.
Acknowledgements
The authorswould like to sincerely thank the research participants
for their participation in this study.We are grateful to
the staff of Raigmore Hospital, Inverness, for their time and
cooperation during the recruitment phase of this project. The
authors would also like to acknowledge Dr Johnson George
for the use of the TABS score in this study.
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