I
t is often referred to as the nation’s other drug problem. Studies indicate anywhere from 45 to 55 percent of adults fail to take their prescriptions as requested by their doctors.
Initiatives to address the problem have had modest success at best, with no significant impact. Health economists estimate the resulting medical costs of medication nonadherence stretch close to $300 billion annually.
The University of Alabama at Birmingham’s Monika Safford, M.D., professor in the Division of Preventive Medicine in the Department of Medicine, and her research team will engage 500 people in Wilcox, Sumter and Pickens counties living with diabetes who report having trouble with medication adherence.
Those taking part will be randomized to either receiving usual care, or working with a community health adviser and watching educational DVDs that include stories of other people from their community who have accepted their disease. These community partners will discuss and show other patients the importance of medication adherence in helping them live full lives.
This is a radically different research approach that is made possible by a three-year, $2 million grant awarded to Safford by the Patient-Centered Outcomes Research Institute, which helps people make informed health care decisions and improves health care delivery and outcomes by producing and promoting high-integrity, evidence-based information that comes from research guided by patients, caregivers and the broader health care community.
“Improving medication adherence is one of the greatest challenges in modern medicine,” said Safford, who is the assistant dean for Continuing Medical Education in the UAB School of Medicine. “Medication adherence is especially critical in regions like rural Alabama, where residents have among the worst health outcomes in the United States. Rates of cardiovascular mortality, diabetes and obesity are very high; but resources are scarce. We hope to reach people who do not embrace their illness, help them come to terms with it, and then help them realize that taking their medications is the key to staying as well as they can for as long as they can.”
Safford says caregivers consistently report talking with patients who have been diagnosed with diabetes or other chronic illnesses but do not accept the diagnosis. Because they have not come to grips with the reality of their illness, it is common for these patients to not take their medication properly. In some cases, they never even fill the prescription.
Safford says one reason for this persistent finding of nonadherence could be that previous interventions rarely acknowledge medications within the larger context of the lived experience of illness.
Safford references the framework of famed sociology researchers Juliet Corbin and Anselm Strauss, who interviewed hundreds of patients in the 1980s to understand the lived experience of illness, eventually developing a research approach known as grounded theory. They asked patients questions about what it is like to be sick, and how it makes them feel to have a chronic illness that will never go away.
Drawing on these patient interviews, Corbin and Strauss showed that chronic illness is a fundamentally destabilizing influence that forces the afflicted to confront the potential limitations of their “new” chronically ill selves. Accepting one’s illness may be a crucial step in embracing medication adherence and other self-management behaviors as ways to restore balance following this disruption.
“The Corbin and Strauss framework is not often used to develop and test interventions to improve medication adherence, and this is the central objective of this proposal,” Safford said. “We will test the hypothesis that an intervention designed within the Corbin and Strauss framework can improve adherence and health outcomes compared to usual care.”
The intervention will consist of educational DVDs with integrated storytelling about how community members accepted their disease and overcame barriers to medication adherence, as well as one-on-one telephonic peer coaching. Researchers will conduct focus groups with patients, create DVDs and the coaching intervention protocol, train peer coaches, and conduct the pilot test.
The randomized controlled trial of 500 individuals with type 2 diabetes and medication nonadherence will compare the effectiveness of usual care and the intervention on medication adherence, as well as physiologic risk factors including A1c, blood pressure and low-density lipoprotein cholesterol (primary outcomes) and quality of life and self-efficacy (secondary outcomes).
This project was designed in collaboration with community partners whose work with UAB over several years has centered around community-engaged research on diabetes and peer coaching interventions.
“This innovative approach would be a major shift in how we help patients in underresourced areas living with chronic diseases commit to taking medications, improving health and eventually reducing health disparities,” Safford said. “If the program works, it could potentially be implemented in any health care setting where community health workers are integrated.”
Other UAB researchers involved in the project include Andrea Cherrington, M.D., associate professor of medicine; Michelle Martin, Ph.D., associate professor of medicine; Joshua Richmond, assistant professor of surgery; and Susan Andreae, project manager.