Original Paper Received: May 13, 2013 Accepted: April 6, 2014 Published online: September 24, 2014
Eur Neurol 2014;72:262–270 DOI: 10.1159/000362718
Barriers and Facilitators for Medication Adherence in Stroke Patients: A Qualitative Study Conducted in French Neurological Rehabilitation Units Stephanie Bauler a Sophie Jacquin-Courtois a Julie Haesebaert b Jacques Luaute a Emmanuel Coudeyre c Corinne Feutrier d Benoit Allenet e Evelyne Decullier b Gilles Rode a Audrey Janoly-Dumenil a, f
a
Pôle de Rééducation et de Réadaptation Fonctionnelles, Hôpital Henry Gabrielle, Hospices Civils de Lyon, Saint Genis Laval, b Pôle Information Médicale, Évaluation, Recherche, Hospices Civils de Lyon, Lyon, c Pôle Rééducation-Réadaptation, Centre Hospitalo-Universitaire, Clermont Ferrand, d Unité D’éducation Thérapeutique du Patient, Hospices Civils de Lyon, Lyon, e Service de Pharmacie Clinique, Centre Hospitalo-Universitaire, Grenoble, f EA 4129 SIS Santé Individu Société, Laboratoire Interuniversitaire de l’Université de Lyon, Lyon, France
Abstract Objective: To describe the perceptions of French patients, caregivers and healthcare professionals on stroke and secondary preventive medications. Method: A qualitative study was conducted, based on four predetermined topics: stroke, secondary prevention medications, patient’s experience, relationship between patient/caregiver and healthcare team. Results: Twenty-six interviews were conducted. Difficulties in taking medications, lack of knowledge on stroke and medication benefits, fear of overmedication were identified as barriers for adherence in patients. Doubts about generic drugs were expressed by caregivers. Healthcare professionals reported lack of knowledge and absence of clinical symptoms as barriers. On the other hand, support from caregivers and healthcare professional support is essential for compli-
© 2014 S. Karger AG, Basel 0014–3022/14/0726–0262$39.50/0 E-Mail [email protected] www.karger.com/ene
ance in all participants. Patients and caregivers expressed that fear of recurrence was a facilitator for treatment compliance. Conclusion: This study highlights the barriers and facilitators for stroke treatment adherence and underlines the similarities and differences between the perceptions of patients, caregivers and healthcare professionals. These results must be integrated into the future French educational programs to improve medication adherence. © 2014 S. Karger AG, Basel
Introduction
Stroke is the third leading cause of death in France and a major cause of acquired disability. Every year, 130,000 new cases of stroke are diagnosed; the risk of recurrence is estimated at between 30 and 43% in the fifth year following the primary stroke [1]. Preventive treatments have shown their effectiveness on stroke recurrence: medications, healthy lifestyle and exercise [2]. However, paAudrey Janoly-Dumenil, PharmD, PhD Hôpital Henry Gabrielle, Hospices Civils de Lyon 20, Route de Vourles FR–69 230 Saint Genis Laval (France) E-Mail audrey.janoly-dumenil @ chu-lyon.fr
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Key Words Stroke · Medication adherence · Perception · Secondary prevention · Qualitative research
tients’ adherence to long-term treatments is quite low [3]. Concerning stroke, medication adherence can vary from 45 to 90% [4–9]. It has been proven that poor adherence results in poor treatment outcomes [7, 10, 11]. Therefore, it is essential to improve secondary preventive medication adherence among stroke survivors. Non-adherence can be intentional or non-intentional [3]. Non-intentional non-adherence is a passive process and often concerns patients with cognitive impairment [12]. Intentional non-adherence is a deliberate behavior that leads to not following medical instructions [12, 13]. Key barriers to poor adherence were identified as concerns about treatment (dependence, toxicity and overmedication) and low perceived benefit of medication [12, 14]. Even though complex interventions in stroke care have yielded minor results [15, 16], some studies did report the significant impact of therapeutic patient education (TPE) programs on medication adherence in stroke survivors [17–19]. Before developing effective TPE programs, it seems essential to analyze the beliefs and expectations of patients and caregivers, since they play a major role in treatment compliance [14]. Health-related behaviors are supported by several theoretical models like the health belief model [20, 21], the social cognitive theory, the theory of planned behavior, the protection-motivation behavior and the self-regulatory model of illness behavior [3]. Regarding the specific issue of medication adherence, Leventhal’s self-regulatory model of illness behavior was highly relevant [3, 22]. In previous studies, this model supported the relationship between medication adherence and beliefs and expectations regarding treatments [8, 12, 18, 23, 24]. In addition to collecting information from patients and caregivers, it seemed relevant to collect experiences from healthcare professionals as they play a significant role in the patients’ care management [25]. Qualitative studies are fitted to explore health behaviors. In stroke pathology, several studies focused on acute care, rehabilitation therapies, life after the acute event, caregivers’ experience and community services [26]. However, very few studies have explored beliefs on secondary prevention drugs. The rare qualitative studies that explored beliefs and behaviors regarding medication adherence concerned mostly primary cardiovascular prevention, thus results could differ from patients’ belief regarding secondary prevention. Chambers et al. analyzed factors that could explain poor medication adherence in stroke patients: forgetting medications, intentionally not taking their treatment, receiving poor support from
healthcare professionals, limited knowledge on treatment or its expected benefits [27]. To this day, no study has compared the beliefs of patients, caregivers and healthcare professionals. Furthermore, beliefs differ from one country to another, based on healthcare systems and access to treatment [3, 24, 28]. To date, no French study has investigated medication beliefs in patients, caregivers and healthcare professionals. The objective of this study was to describe beliefs and expectations of French patients, caregivers and healthcare professionals in order to define barriers and facilitators for medication adherence in stroke patients in the framework of secondary preventive treatment.
Medication Adherence for Stroke Patients: Barriers and Facilitators
Eur Neurol 2014;72:262–270 DOI: 10.1159/000362718
Method Semi-structured interviews were conducted by the first and last authors (SB and AJD) between December 2011 and April 2012 within four neurological rehabilitation units belonging to the second largest French teaching hospital (Hospices Civils de Lyon).
Protocol The themes of the semi-structured interview were previously identified by the WHO as having an influence on medication adherence [3]: stroke beliefs, medication issues, patient experience and relationships with healthcare professionals. Guides were specifically developed by a multidisciplinary team (three physicians, two pharmacists and one psychologist) to conduct the semi-structured interviews. For patients and caregivers, the guide (table 1) was based on a review of the relevant literature [23, 29–32]. The discussion was not limited to predetermined areas of inquiry. Participants’ demographics were collected. A pilot interview was carried out with a stroke survivor and caregiver in order to validate the guide’s design. Participants were interviewed during a rehabilitation consultation (outpatient) or during post-stroke hospitalization (inpatient). We met patients at different times post
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Participants Patients/caregivers: patients were recruited either as outpatients or inpatients of the neurological rehabilitation units. Inclusion criteria: >18 years, history of ischemic stroke (at least two months post stroke), taking at least two drugs for secondary prevention, self-management of medications, returning home after hospital discharge (inpatient). Exclusion criteria: aphasia, psychiatric disorders or severe cognitive disorders. Inclusion criteria for caregivers: >18 years, being a family member of the patient and managing his or her medication after discharge from the hospital. Patients and caregivers were recruited separately in this study. Inclusion criterion for healthcare professionals: to work in one of the four neurological rehabilitation units. It was decided to recruit 1 physician and 2 nurses (random selection) from each of the 4 rehabilitation units included in the study. All study participants had to be able to communicate in French and give their oral consent.
Main themes
Issues (patient)
Issues (caregiver)
Stroke, risks and recurrence
Can you explain your disease? The circumstances surrounding the disease? What are your main concerns?
Can you explain her/his disease? The circumstances surrounding the disease? What are your main concerns?
Define secondary preventive medication
What do you think secondary preventive medication mean? What does it include?
What do you think secondary preventive medication mean? What does it include?
Current treatment
Which drugs are you currently taking? How many are you taking?
Which drugs does she/he currently take? How many is she/he taking?
Current beliefs about medication
Why do you think you were prescribed this medical treatment? Are you aware of your treatment’s benefits? Which kind of advice would you like to receive regarding your medications?
Why do you think she/he was prescribed this medical treatment? Are you aware of the treatment’s benefits? Which type of information would you like to receive regarding these medications?
Previous experiences
Can you tell me which drugs you were taking before your stroke?
Do you know which drugs he/she was taking before the stroke?
Have you taken drugs before? How was your experience with your previous treatment? (benefits, side effects, over/under dosage)
Are you currently taking medications? And how is your experience with drugs? (benefits, side effects, over/under dosage)
Motivation
What motivates you to take your treatment?
In your opinion, what motivates medication adhesion?
Main barriers to medication adherence
What are the reasons for sometimes not taking your medication?
Daily treatment: how to help?
How do you manage your treatment? Do you need some help? (alarm reminders, nurse, caregiver, …)
Lifestyle changes
After your stroke diagnosis did you change your diet or lifestyle habits? Do you practice a sport regularly?
In your opinion, what diet and lifestyle habits changes are important after a stroke?
Healthcare (relationships with specialists, general practitioners, laboratory staff, pharmacist, nurses, …)
Do you think the organization of the healthcare system is appropriate?
Do you think the organization of the healthcare system is appropriate?
Relationships with the healthcare team (physician, pharmacist, nurse, physiotherapist, …)
How would you evaluate your relationships with the medical staff? Do you think it should be improved?
How would you evaluate your relationships with the medical staff? Do you think it should be improved?
Deep barriers mentioned by patients/caregivers
Reminders and reformulation of what was said… (= brief summary of the interview)
Reminders and reformulation of what was said… (= brief summary of the interview)
stroke. For healthcare professionals, the interview guide (table 2) was designed based on previously published methodologies [29, 33]. Each participant was informed of the study objectives and they all signed an informed consent form before the interview. The study was approved by the local ethics committee and registered with the French Data Protection Agency (CNIL) in February 2012.
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Data Analysis Each interview was recorded and ad verbatim transcriptions were provided. Some of them were presented in the results to illustrate the analysis. Transcripts were analyzed separately using an inductive approach. Discordances were solved by consensus. A manual data analysis was conducted based on three validated steps [34]: (1) condensing raw text data into a brief,
Bauler et al.
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Table 1. Guide to conduct the semi-structured interviews with patient or caregiver
Table 2. Guide to conduct the semi-structured interviews with health professionals
Main themes
Issues
Stroke, risk and recurrences
How do you think patients apprehend their disease? Do you systematically provide information? Do you think you provide enough information?
Define secondary preventive medication
Do you think you provide enough information on stroke medication? Do you talk about ‘secondary medication after stroke’? Do you use these exact words? How do you explain new treatments?
Current treatment
Do you advise patients on the proper use of medication or explain the pharmacology? Do you think patients follow your advices?
Motivation
What do you think are the motivations for patients to keep taking their medicines? How do you encourage them to take their medicines? Do you think stroke survivors are good compliers?
Treatment benefits
Do you believe that secondary prevention post stroke is helpful? Do you think patients understand the benefits of stroke treatments?
Main barriers to medication adherence
In your opinion, what are the reasons why patients do not take their medications? (listing of barriers to medication adherence)
Daily treatment: how to help?
Do you think patients need help managing their daily treatment? What would be good notions to be implemented?
Improving care
What do you think can be improved to increase compliance and facilitate drug taking?
Table 3. Characteristics of stroke survivors
Patient (n), Inpatient Age at time Time elapsed Stroke location gender (yes/no) of interview since stroke (years) (years, months)
Communication Medical treatment Caregiver disorders management at interviewed discharge (yes/no)
1, Male 2, Female 3, Female 4, Male 5, Female 6, Male 7, Male 8, Female 9, Male 10, Female 11, Male 12, Male 13, Male 14, Male
no no no no no dysarthria dysarthria no aphasia aphasia aphasia no aphasia no
66 63 40 67 52 48 38 53 56 78 40 63 66 57
2m 1m 4m 5y2m 1y1m 2m 2y3m 2y 1m 10 y 4 m 4y8m 4y7m 2m 5y8m
brainstem brainstem right hemisphere right hemisphere brainstem (laterobulbar) right hemisphere left hemisphere right hemisphere left hemisphere left hemisphere left hemisphere left hemisphere left hemisphere right hemisphere
patient patient patient patient patient patient patient patient caregiver caregiver caregiver caregiver caregiver caregiver
no no no no no no no no yes yes yes yes yes yes
Results
summarized format; (2) establishing clear links between the evaluation or research objectives and findings derived from raw data; (3) developing a framework for the underlying mechanisms of experiences, which are obvious in the raw data. The goal was to identify frequent, dominant or significant themes and keywords and categorize these findings according to the four research themes.
Participants Patients and Caregivers: 14 Interviews Characteristics of stroke survivors are presented in table 3. They were taking a mean of 9 different drugs (SD:
Medication Adherence for Stroke Patients: Barriers and Facilitators
Eur Neurol 2014;72:262–270 DOI: 10.1159/000362718
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yes yes yes no no yes no no yes no no no yes no
Health professional
Number interviewed
Sex
Age, years
Resident (physician) Resident (physician) Physician MD, PhD Physician MD, PhD Senior nurse Nurses
1 1 1 1 1 7
male male male female female female
28 25 40 38 42 28 (23–35)*
* Mean (min–max).
4, range: 3–15), 79% of them had mobility impairments (hemiplegia) and 43% had speech disorders (aphasia, dysarthria). In average, each interview lasted about 22 min (SD: 4 min, range 16–30). Healthcare Professionals: 12 Interviews Four physicians and 8 nurses were interviewed. Characteristics are presented in table 4 and each interview lasted about 16 min (SD: 4 min, range 11–24). No subject refused to participate. Results are presented according to the four predetermined research themes. For healthcare professionals (P) = Physician, (N) = Nurse are indicated next to their quotes. Stroke Beliefs Patients Stroke came as a surprise for all patients, despite presenting many risk factors beforehand. ‘We don’t know where my stroke came from’, ‘it’s a little bit complicated’, ‘I never thought I would have a stroke’, ‘I did not expect it. I had no forewarning’. Caregivers Caregivers seemed to better understand the origins of the stroke and identified risk factors as ‘drinking, smoking and poor lifestyle habits’. They also widened their knowledge by doing an Internet search: ‘We looked on the Internet to find information on the disease and why we needed this treatment’. Healthcare Professionals Illness awareness depended on the patient’s profile and location of the stroke, that is, left or right side. ‘In patients with aphasia, illness awareness was impaired’ (P), ‘In patients with anosognosia, we repeat treatment rec266
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ommendations to no avail. It is more common for rightsided stroke patients’ (P). ‘Patients with aphasia have impaired speaking abilities. They might understand everything but cannot voice it’ (N). Healthcare professionals told us they were convinced they needed to adapt their speech to each patient or caregiver. ‘We tried explaining using words easily understandable by the patients and their family’ (P), ‘I repeat the information several times’ (P). Medications Issues Patients Stroke survivors were concerned with side effects of their medications: ‘Medications have more side effects than advantages’, ‘We treat the affected side, but the other side must bear the negative effects of the drugs’. They reported a lot of practical issues such as medication schedule or difficulties in taking the medications: ‘Should I take the drugs at set times?’, ‘It is not easy to cut the tablets in half’. They also voiced their fear of overmedication. ‘All these drugs are really strong’, ‘It is a low dose, perhaps I don’t need to be worried, but...’. Nevertheless, patients were aware of the absolute necessity of the treatment, in order to prevent a new stroke: ‘I have no choice; if I don’t take the medication, I will have a new stroke’, ‘I know I could die if I don’t take my medication’ …‘Of course remaining alive and well motivates me to take all these drugs’. Caregivers Similarly, caregivers also reported medication-related issues and concerns about generic drugs: ‘We concluded that it was a generic drug’, ‘Sometimes there are some problems with the pharmacy due to generic drugs’, ‘It has to be the real clopidogrel, not the generic drug, because sometimes they might give us another molecule, you never know’. They also feared overmedication: ‘The drugs they gave her were too strong, there are too many different types of drugs, and we can’t figure it out’. They were aware of the importance of treatment to prevent a new stroke: ‘I’m very serious with medications, I understand perfectly their impact on his life’. Healthcare Professionals Physicians were aware of not giving enough information on drug intake. ‘I don’t give out details about it’ (P), ‘We do not systematically inform the patients about precautions to be taken with this medication’ (P), ‘No, we don’t explain’ (N). According to physicians, a good time to deliver this information would be when they hand out Bauler et al.
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Table 4. Health professional characteristics
Patient Experience Patients Concerns about post-stroke changes were frequently reported by survivors, such as fear of recurrence: ‘Another one may happen’, ‘I could have another one and it scares me’. Lifestyle changes post-stroke were also brought up ‘We might need some time to get used to the condition’, ‘Our life will never be the same again’, ‘I told myself that things will no longer be ‘normal’. Concerning previous experience with drugs, all patients reported previous adverse events they had experienced: I experienced side effects with the drugs I took prior to the stroke: ‘diarrhea with metformin’, ‘insomnia with analgesics’, ...‘I had a lot of problems with medications’. Caregivers The impact of the first stroke is quite important and fear of recurrence is also expressed by caregivers: ‘We are still afraid of stroke recurrence’. They also brought up difficulties with these life changes. Furthermore, they expressed negative experience with the drugs ‘My mother had some issues with this medication before, so I am being careful’.
Relationships with Healthcare Professionals Patients They reported their relationships with healthcare professionals as ideal. ‘It went well’, ‘Perfect relationship with physicians and nurses’. Pharmacists are often well considered by patients, but only as they easily deliver the medications. ‘At the pharmacy: they do not need to give me advice since I come with a prescription’. Caregivers However, caregivers expressed divergent opinions about healthcare professionals. ‘We needed more information’, ‘Physicians have to be clearer’, ‘Their speech is too complicated and not adapted’. ‘We have a good relationship with our pharmacy. If we have a problem with renewing the prescription, they can easily give us one month treatment in advance’. Healthcare Professionals They all agreed on the need to deliver more information to their patients. ‘We should provide them with more information’ (P), ‘We should improve the way we deliver information on risks and recurrences’ (P). Caregivers are essential to the care management of stroke patient and thus need to be considered right from the beginning. ‘We have to involve the family’ (P). It is more difficult for patients to manage their treatment by themselves. The presence of family is a facilitator: ‘People with family or with a good social support have fewer difficulties in managing their treatment’ (N). Physicians also underline that patients will exhibit better treatment compliance with regular medical follow-up. ‘I insist that patients go to their family physician’ (P). They expressed that patients and caregivers need to trust their physician, it is essential in order to improve treatment compliance.
Discussion
Healthcare Professionals According to physicians and nurses, they do not often bring up the risk of recurrence with their patients. ‘We don’t talk about it, because they are already so anxious’ (N), ‘We explain it progressively and adapt our speech to each patient’ (P). They said that this issue is discussed only when patients exhibit a lot of risk factors, despite them being aware of the topic’s importance ‘They have to understand that they could have another stroke’ (N).
This is the first French qualitative study exploring the perceptions of stroke and secondary prevention treatments. Furthermore, this study is also original as it compares the perceptions of patients, caregivers and healthcare professionals.
Medication Adherence for Stroke Patients: Barriers and Facilitators
Eur Neurol 2014;72:262–270 DOI: 10.1159/000362718
Stroke Beliefs In our study, patients often had troubles understanding the objectives of post-stroke treatment. Conversely, caregivers were well aware of stroke risk factors and their 267
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the prescription to their patients. ‘I think that taking the time to explain the prescription to outpatients is really important’ (P). It is necessary to adapt the drug intake to the patient’s daily life. ‘Trying to decrease the number of different treatments, using a combination of drugs when possible …/… considering the patient’s preferences regarding galenic formulation’ (P), ‘Taking the time to discuss their medication schedule’ (P), ‘Since they cannot observe the effects of the drugs, they think them unnecessary’ (N). Healthcare professionals brought up the issue of not having clinical symptoms: ‘They do not feel sick so they think that if they do not take their medications they will not be sick. It’s a perverse reasoning’ (P), ‘Patients are tempted to stop taking their medications as they no longer exhibit clinical symptoms’ (N).
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liefs, communication around generics and their use [44]. Allenet et al., explored attitudes toward generics and three main elements that could explain them: (1) erroneous personal beliefs and knowledge and suspicion on the quality of the generics, (2) relationship with healthcare professionals and (3) previous experience with generics. So, communication around generics is essential to anticipate any resistance and adapt the prescription according to patients’ beliefs and preferences [42]. Patient Experience. Fear of stroke recurrence was also widely addressed during the interviews with patients and caregivers. Few studies have highlighted this element before. A study on antihypertensive drugs reported fear of complications as a facilitator for medication adherence. Nevertheless, fear of recurrence was not studied since it focused on primary prevention and no symptomatic cardiovascular event had happened [23]. Regarding stroke survivors, Chambers et al., showed that understanding the consequences of not taking the prescribed treatment led to better medication adherence. In our study, this appears to be a sensitive topic to discuss with patients [27] even though physicians agree that they do not discuss it often. Gale et al., reported that a patient’s attitude regarding medications depended on whether his or her condition was life-threatening and if medical treatment was the best and only therapeutic [40]. Stroke survivors need to adapt to their new life, yet caregivers’ lives are also impacted since patients often exhibit post-stroke motor impairments and need help. For caregivers, these difficulties of adapting to a ‘new’ life were previously reported [26, 45]. Rehabilitation focuses on the patient but caregivers have to be considered. Relationships with Healthcare Professionals. Our study reports good relationships between patients/caregivers and healthcare professionals. Nevertheless, patients generally evaluated the relationship as very good, while caregivers expressed divergent opinions. As previously described, caregivers should be considered more by healthcare teams [46], since they in turn support the patient [27, 47]. Caregivers seem to expect more from their family physician than patients [48], corroborating our results. In the present study, caregivers appreciate communicating with retail pharmacists. Conversely, patients do not think pharmacists should deliver advice and prefer talking to their doctor. Previous studies also found the same results: pharmacists are considered more like a drug supplier than a healthcare professional [23]. In order to ensure treatment compliance, it is essential to facilitate communication between patients, caregivers and healthcare professionals [26, 49] and improve partnerships between Bauler et al.
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involvement and support can help improve medication adherence in stroke patients. Healthcare professionals were aware that they needed to explain the origin of the stroke to their patients. Previous studies have highlighted the absence of knowledge regarding stroke and risk factors. Samsa et al., reported misconceptions in stroke survivors: 58% were unaware of their increased risk of having a subsequent stroke [35]. An Australian survey showed 50% of stroke survivors had insufficient knowledge based on a stroke knowledge score. Furthermore, stroke survivors were not more knowledgeable about the disease than non-stroke survivors [36]. For improving stroke knowledge in this population, it seems necessary to provide more information. Sullivan et al., reported the relevance of delivering educational pamphlets to provide more information through written educational material with other educational tools such as informative discussion and educational lectures [37]. Green et al., showed the impact of therapeutic patient education (TPE) interventions to increase knowledge in stroke survivors [38]. Corroborating these studies, Smith et al., validated the more effective interventions for improving knowledge were the ones that actively involved patients and caregivers and not the ones that only involved passive interventions [39]. In our study, stroke came as a surprise to all patients. As seen in the literature, patients have difficulties being aware of the severity of their illness when they exhibit no symptoms [23]. Medication Issue. In our study, patients and caregivers reported needing more information on drug intake (dosage, schedule and benefits/side effects). According to previous studies, healthcare professionals were also aware of not delivering enough practical information on drug intake. Gale et al., reported that family physicians were aware that they needed to explain what preventive medication was and its benefits [40] because patients did not take medication when they did not understand the benefits of a particular treatment [12, 41]. Furthermore, in the literature, stroke patients exhibited little knowledge on stroke medications and expressed concerns about side effects and fear of overmedication [12, 27]. In our study, contrary to healthcare professionals, caregivers expressed specific reservations about generic drugs; yet this issue was only rarely reported in the literature [42] but could represent a barrier for medication adherence. Previous studies reported the ambivalence of healthcare professionals concerning generic drugs, despite no validated evidence regarding differences in clinical outcomes between generics and brand-name drugs [43]. In fact, Shrank et al., showed a relationship between patients’ be-
hospital pharmacists and retail pharmacists and family physicians and specialists. Bushnell et al., reported better treatment compliance and better medication knowledge when patients had a scheduled appointment with their family physician upon discharge [9]. In previous studies, limited access to medication [3, 23, 24, 28] and inadequate healthcare system where reported as barriers for medication adherence affecting the relationship between patients and healthcare professionals. Since the French healthcare system allows free access to medication, it could explain why these issues were not reported here and probably do not constitute a major barrier for treatment compliance in French stroke survivors. Study Limits One limit of this study was that the patients and caregivers who were interviewed were not related to each other. It could have helped understand the changes in patient/caregiver relationship after stroke although that was not the objective of this work. Because of the small sample, it was impossible to compare the beliefs of nurses and physicians. Finally, medication adherence was not evaluated since some of the patients interviewed had just started their treatment. Consequently, we cannot formally validate a correlation between the beliefs expressed during the interviews and medication adherence.
Conclusion
Optimal medication adherence in stroke survivors is necessary for preventing recurrences. Taking into account beliefs from patients and caregivers, according to theoretical models of health-related behavior, is essential to reduce intentional non-adherence, often a consequence of erroneous representations. Our study was the first to specifically explore French beliefs surrounding medical treatments. Besides well-known barriers and facilitators for treatment compliance, our study showed new concerns about generic drugs and, contrary to popular belief, that the fear of stroke recurrence was actually a facilitator to medication adherence. These findings should be implemented into the future French educational programs.
Acknowledgments We would like to thank the patients, caregivers, nurses and physicians for having participated in this study and Bénédicte Clement for the translation of the manuscript.
Disclosure Statement None.
References
Medication Adherence for Stroke Patients: Barriers and Facilitators
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9
10
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therapy on recurrent ischemic stroke and predictors of nonpersistence among ischemic stroke survivors. Curr Med Res Opin 2010;26: 1023–1030. Sjölander M, Eriksson M, Glader EL: The association between patients’ beliefs about medicines and adherence to drug treatment after stroke: a cross-sectional questionnaire survey. BMJ Open 2013;3:e003551, DOI: 10.1136/bmjopen-2013–003551. Bushnell C, Olson D, Zhao X, Pan W, Zimmer L, Goldstein L, Alberts MJ, Fagan SC, Fonarow GC, Johnston SC, Kidwell C, Labresh KA, Ovbiagele B, Schwamm L, Peterson ED; AVAIL Investigators: Secondary preventive medication persistence and adherence 1 year after stroke. Neurology 2011;77:1182–1190. Ji R, Liu G, Shen H, Wang Y, Li H, Peterson E, Wang Y: Persistence of secondary prevention medications after acute ischemic stroke or transient ischemic attack in Chinese population: data from China National Stroke Registry. Neurol Res 2013;35:29–36. Perreault S, Yu AYX, Côté R, Dragomir A, White-Guay B, Dumas S: Adherence to anti-
12
13
14
15
16
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hypertensive agents after ischemic stroke and risk of cardiovascular outcomes. Neurology 2012;79:2037–2043. O’Carroll R, Whittaker J, Hamilton B, Johnston M, Sudlow C, Dennis M: Predictors of adherence to secondary preventive medication in stroke patients. Ann Behav Med 2010; 41:383–390. Gadkari AS, McHorney CA: Unintentional non-adherence to chronic prescription medications: how unintentional is it really? BMC Health Serv Res 2012;12:98, DOI: 10.1186/ 1472–6963–12–98. Horne R, Weinman J: Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. J Psychosom Res 1999;47:555–567. Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X: Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2008;2:CD000011, DOI: 10.1002/14651858. Redfern J, McKevitt C, Wolfe CD: Development of complex interventions in stroke care: a systematic review. Stroke 2006; 37: 2410– 2419.
269
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/14/2015 3:05:34 AM
1 Haute Autorité de Santé: Prevention of stroke. Report. France, 2009. 2 Davis SM, Donnan GA: Clinical practice. Secondary prevention after ischemic stroke or transient ischemic attack. N Engl J Med 2012; 366:1914–1922. 3 World Health Organisation: Adherence to long-term therapies: evidence for action. Geneva, WHO, 2003. 4 Sappok T, Faulstich A, Stuckert E, Kruck H, Marx P, Koennecke HC: Compliance with secondary prevention of ischemic stroke. Stroke 2001;32:1884–1889. 5 Hamann GF, Weimar C, Glahn J, Busse O, Diener HC: Adherence to secondary stroke prevention strategies – results from the German Stroke Data Bank. Cerebrovasc Dis 2003;15:282–288. 6 De Schryver EL, Van Gijn J, Kappelle LJ, Koudstaal PJ, Algra A; for the Dutch TIA trial and SPIRIT study groups: Non-adherence to aspirin or oral anticoagulants in secondary prevention after ischaemic stroke. J Neurol 2005;252:1316–1321. 7 Burke JP, Sander S, Shah H, Zarotsky V, Henk H: Impact of persistence with antiplatelet
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28 Schafheutle EI, Hassell K, Noyce PR, Weiss MC: Access to medicines: cost as an influence on the views and behaviour of patients. Health Soc Care Community 2002;10:187–195. 29 Williams AF, Manias E, Walker R: Adherence to multiple, prescribed medications in diabetic kidney disease: a qualitative study of consumers’ and health professionals’ perspectives. Int J Nurs Stud 2008;45:1742–1756. 30 Goff SL, Mazor KM, Meterko V, Dodd K, Sabin J: Patients’ beliefs and preferences regarding doctors’ medication recommendations. J Gen Intern Med 2008;23:236–241. 31 Yeung SM, Wong FKY, Mok E: Holistic concerns of Chinese stroke survivors during hospitalization and in transition to home. J Adv Nurs 2011;67:2394–2405. 32 White JH, Magin P, Attia J, Pollack MR, Sturm J, Levi CR: Exploring poststroke mood changes in community-dwelling stroke survivors: a qualitative study. Arch Phys Med Rehabil 2008;89:1701–1707. 33 Wens J, Vermeire E, Royen PV, Sabbe B, Denekens J: GPs’ perspectives of type 2 diabetes patients’ adherence to treatment: a qualitative analysis of barriers and solutions. BMC Fam Pract 2005, DOI: 10.1186/1471–2296–6– 20. 34 Thomas DR: A general inductive approach for analyzing qualitative evaluation data. Am J Eval 2006;27:237–246. 35 Samsa GP, Cohen SJ, Goldstein LB, Bonito AJ, Duncan PW, Enarson C, DeFriese GH, Horner RD, Matchar DB: Knowledge of risk among patients at increased risk for stroke. Stroke 1997;28:916–921. 36 Sullivan K, White K, Young R, Chang A, Roos C, Scott C: The nature and predictors of stroke knowledge amongst at risk elderly persons in Brisbane, Australia. Disabil Rehabil 2006;28:1339–1348. 37 Sullivan KA, Katajamaki A: Stroke education: retention effects in those at low- and high-risk of stroke. Patient Educ Couns 2009; 74: 205– 212. 38 Green T, Haley E, Eliasziw M, Hoyte K: Education in stroke prevention: efficacy of an educational counselling intervention to increase knowledge in stroke survivors. Can J Neurosci Nurs 2007;29:13–20.
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39 Smith J, Forster A, House A, Knapp P, Wright J, Young J: Information provision for stroke patients and their caregivers. Cochrane Database Syst Rev 2008;2:CD001919, DOI: 10.1002/14651858. 40 Gale NK, Greenfield S, Gill P, Gutridge K, Marshall T: Patient and general practitioner attitudes to taking medication to prevent cardiovascular disease after receiving detailed information on risks and benefits of treatment: a qualitative study. BMC Fam Pract 2011;12:59, DOI: 10.1186/1471–2296–12–59. 41 Clifford S, Barber N, Horne R: Understanding different beliefs held by adherers, unintentional nonadherers, and intentional nonadherers: application of the Necessity-Concerns Framework. J Psychosom Res 2008;64:41–46. 42 Allenet B, Golay A: What are patients’ attitudes towards generic drugs? The example of metformin. Rev Med Suisse 2013; 9: 1005– 1009. 43 Decollogny A, Eggli Y, Halfon P, Lufkin TM: Determinants of generic drug substitution in Switzerland. BMC Health Serv Res 2011; 11:17, DOI: 10.1186/1472–6963–11–17. 44 Shrank WH, Stedman M, Ettner SL, DeLapp D, Dirstine J, Brookhart MA, Fischer MA, Avorn J, Asch SM: Patient, physician, pharmacy, and pharmacy benefit design factors related to generic medication use. J Gen Intern Med 2007;22:1298–1304. 45 Jones L, Morris R: Experiences of adult stroke survivors and their parent carers: a qualitative study. Clin Rehabil 2013;27:272–280. 46 Cameron JI, Naglie G, Silver FL, Gignac MA: Stroke family caregivers’ support needs change across the care continuum: a qualitative study using the timing it right framework. Disabil Rehabil 2013;35:315–324. 47 Greenwood N, Mackenzie A, Harris R, Fenton W, Cloud G: Perceptions of the role of general practice and practical support measures for carers of stroke survivors: a qualitative study. BMC Fam Pract 2011;12:57, DOI: 10.1186/1471–2296–12–57. 48 Brotheridge S, Young J, Dowswell G, Lawler J, Forster A: A preliminary investigation of patient and carer expectations of their general practitioner in longer-term stroke care. J Eval Clin Pract 1998;4:237–241. 49 Eames S, Hoffmann T, Worrall L, Read S: Stroke patients’ and carers’ perception of barriers to accessing stroke information. Top Stroke Rehabil 2010;17:69–78.
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17 Ovbiagele B, Saver JL, Fredieu A, Suzuki S, Selco S, Rajajee V, McNair N, Razinia T, Kidwell CS: In-hospital initiation of secondary stroke prevention therapies yields high rates of adherence at follow-up. Stroke 2004; 35:2879–2883. 18 O’Carroll RE, Chambers JA, Dennis M, Sudlow C, Johnston M: Improving adherence to medication in stroke survivors: a pilot randomised controlled trial. Ann Behav Med 2013;46:358–368. 19 Lummis H, Sketris I, Gubitz G, Joffres M, Flowerdew G: Medication persistence rates and factors associated with persistence in patients following stroke: a cohort study. BMC Neurol 2008;8:25, DOI: 10.1186/1471–2377– 8–25. 20 Sullivan KA, White KM, Young RM, Scott C: Predicting behaviour to reduce stroke risk in at-risk populations: the role of beliefs. Int J Ther Rehabil 2009;16:488–496. 21 Sullivan KA, White KM, Young RM, Chang A, Roos C, Scott C: Predictors of intention to reduce stroke risk among people at risk of stroke: an application of an extended health belief model. Rehabil Psychol 2008; 53: 505– 512. 22 Leventhal H, Diefenbach M, Leventhal EA: Illness cognition: using common sense to understand treatment adherence and affect cognition interactions. Cognitive Ther Res 1992; 16:143–163. 23 Tsiantou V, Pantzou P, Pavi E, Koulierakis G, Kyriopoulos J: Factors affecting adherence to antihypertensive medication in Greece: results from a qualitative study. Patient Prefer Adherence 2010;4:335–343. 24 Kronish IM, Diefenbach MA, Edmondson DE, Phillips LA, Fei K, Horowitz CR: Key barriers to medication adherence in survivors of strokes and transient ischemic attacks. J Gen Intern Med 2013;28:675–682. 25 Fried TR, Tinetti ME, Iannone L: Primary care clinicians’ experiences with treatment decision making for older persons with multiple conditions. Arch Intern Med 2011; 171: 75–80. 26 McKevitt C, Redfern J, Mold F, Wolfe C: Qualitative studies of stroke: a systematic review. Stroke 2004;35:1499–1505. 27 Chambers JA, O’Carroll RE, Hamilton B, Whittaker J, Johnston M, Sudlow C, Dennis M: Adherence to medication in stroke survivors: a qualitative comparison of low and high adherers. Br J Health Psychol 2011; 16: 592– 609.
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Barriers and Facilitators for Medication Adherence in Stroke Patients: A Qualitative Study Conducted in French Neurological Rehabilitation Units Stephanie Bauler a Sophie Jacquin-Courtois a Julie Haesebaert b Jacques Luaute a Emmanuel Coudeyre c Corinne Feutrier d Benoit Allenet e Evelyne Decullier b Gilles Rode a Audrey Janoly-Dumenil a, f
a
Pôle de Rééducation et de Réadaptation Fonctionnelles, Hôpital Henry Gabrielle, Hospices Civils de Lyon, Saint Genis Laval, b Pôle Information Médicale, Évaluation, Recherche, Hospices Civils de Lyon, Lyon, c Pôle Rééducation-Réadaptation, Centre Hospitalo-Universitaire, Clermont Ferrand, d Unité D’éducation Thérapeutique du Patient, Hospices Civils de Lyon, Lyon, e Service de Pharmacie Clinique, Centre Hospitalo-Universitaire, Grenoble, f EA 4129 SIS Santé Individu Société, Laboratoire Interuniversitaire de l’Université de Lyon, Lyon, France
Abstract Objective: To describe the perceptions of French patients, caregivers and healthcare professionals on stroke and secondary preventive medications. Method: A qualitative study was conducted, based on four predetermined topics: stroke, secondary prevention medications, patient’s experience, relationship between patient/caregiver and healthcare team. Results: Twenty-six interviews were conducted. Difficulties in taking medications, lack of knowledge on stroke and medication benefits, fear of overmedication were identified as barriers for adherence in patients. Doubts about generic drugs were expressed by caregivers. Healthcare professionals reported lack of knowledge and absence of clinical symptoms as barriers. On the other hand, support from caregivers and healthcare professional support is essential for compli-
© 2014 S. Karger AG, Basel 0014–3022/14/0726–0262$39.50/0 E-Mail [email protected] www.karger.com/ene
ance in all participants. Patients and caregivers expressed that fear of recurrence was a facilitator for treatment compliance. Conclusion: This study highlights the barriers and facilitators for stroke treatment adherence and underlines the similarities and differences between the perceptions of patients, caregivers and healthcare professionals. These results must be integrated into the future French educational programs to improve medication adherence. © 2014 S. Karger AG, Basel
Introduction
Stroke is the third leading cause of death in France and a major cause of acquired disability. Every year, 130,000 new cases of stroke are diagnosed; the risk of recurrence is estimated at between 30 and 43% in the fifth year following the primary stroke [1]. Preventive treatments have shown their effectiveness on stroke recurrence: medications, healthy lifestyle and exercise [2]. However, paAudrey Janoly-Dumenil, PharmD, PhD Hôpital Henry Gabrielle, Hospices Civils de Lyon 20, Route de Vourles FR–69 230 Saint Genis Laval (France) E-Mail audrey.janoly-dumenil @ chu-lyon.fr
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Key Words Stroke · Medication adherence · Perception · Secondary prevention · Qualitative research
tients’ adherence to long-term treatments is quite low [3]. Concerning stroke, medication adherence can vary from 45 to 90% [4–9]. It has been proven that poor adherence results in poor treatment outcomes [7, 10, 11]. Therefore, it is essential to improve secondary preventive medication adherence among stroke survivors. Non-adherence can be intentional or non-intentional [3]. Non-intentional non-adherence is a passive process and often concerns patients with cognitive impairment [12]. Intentional non-adherence is a deliberate behavior that leads to not following medical instructions [12, 13]. Key barriers to poor adherence were identified as concerns about treatment (dependence, toxicity and overmedication) and low perceived benefit of medication [12, 14]. Even though complex interventions in stroke care have yielded minor results [15, 16], some studies did report the significant impact of therapeutic patient education (TPE) programs on medication adherence in stroke survivors [17–19]. Before developing effective TPE programs, it seems essential to analyze the beliefs and expectations of patients and caregivers, since they play a major role in treatment compliance [14]. Health-related behaviors are supported by several theoretical models like the health belief model [20, 21], the social cognitive theory, the theory of planned behavior, the protection-motivation behavior and the self-regulatory model of illness behavior [3]. Regarding the specific issue of medication adherence, Leventhal’s self-regulatory model of illness behavior was highly relevant [3, 22]. In previous studies, this model supported the relationship between medication adherence and beliefs and expectations regarding treatments [8, 12, 18, 23, 24]. In addition to collecting information from patients and caregivers, it seemed relevant to collect experiences from healthcare professionals as they play a significant role in the patients’ care management [25]. Qualitative studies are fitted to explore health behaviors. In stroke pathology, several studies focused on acute care, rehabilitation therapies, life after the acute event, caregivers’ experience and community services [26]. However, very few studies have explored beliefs on secondary prevention drugs. The rare qualitative studies that explored beliefs and behaviors regarding medication adherence concerned mostly primary cardiovascular prevention, thus results could differ from patients’ belief regarding secondary prevention. Chambers et al. analyzed factors that could explain poor medication adherence in stroke patients: forgetting medications, intentionally not taking their treatment, receiving poor support from
healthcare professionals, limited knowledge on treatment or its expected benefits [27]. To this day, no study has compared the beliefs of patients, caregivers and healthcare professionals. Furthermore, beliefs differ from one country to another, based on healthcare systems and access to treatment [3, 24, 28]. To date, no French study has investigated medication beliefs in patients, caregivers and healthcare professionals. The objective of this study was to describe beliefs and expectations of French patients, caregivers and healthcare professionals in order to define barriers and facilitators for medication adherence in stroke patients in the framework of secondary preventive treatment.
Medication Adherence for Stroke Patients: Barriers and Facilitators
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Method Semi-structured interviews were conducted by the first and last authors (SB and AJD) between December 2011 and April 2012 within four neurological rehabilitation units belonging to the second largest French teaching hospital (Hospices Civils de Lyon).
Protocol The themes of the semi-structured interview were previously identified by the WHO as having an influence on medication adherence [3]: stroke beliefs, medication issues, patient experience and relationships with healthcare professionals. Guides were specifically developed by a multidisciplinary team (three physicians, two pharmacists and one psychologist) to conduct the semi-structured interviews. For patients and caregivers, the guide (table 1) was based on a review of the relevant literature [23, 29–32]. The discussion was not limited to predetermined areas of inquiry. Participants’ demographics were collected. A pilot interview was carried out with a stroke survivor and caregiver in order to validate the guide’s design. Participants were interviewed during a rehabilitation consultation (outpatient) or during post-stroke hospitalization (inpatient). We met patients at different times post
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Participants Patients/caregivers: patients were recruited either as outpatients or inpatients of the neurological rehabilitation units. Inclusion criteria: >18 years, history of ischemic stroke (at least two months post stroke), taking at least two drugs for secondary prevention, self-management of medications, returning home after hospital discharge (inpatient). Exclusion criteria: aphasia, psychiatric disorders or severe cognitive disorders. Inclusion criteria for caregivers: >18 years, being a family member of the patient and managing his or her medication after discharge from the hospital. Patients and caregivers were recruited separately in this study. Inclusion criterion for healthcare professionals: to work in one of the four neurological rehabilitation units. It was decided to recruit 1 physician and 2 nurses (random selection) from each of the 4 rehabilitation units included in the study. All study participants had to be able to communicate in French and give their oral consent.
Main themes
Issues (patient)
Issues (caregiver)
Stroke, risks and recurrence
Can you explain your disease? The circumstances surrounding the disease? What are your main concerns?
Can you explain her/his disease? The circumstances surrounding the disease? What are your main concerns?
Define secondary preventive medication
What do you think secondary preventive medication mean? What does it include?
What do you think secondary preventive medication mean? What does it include?
Current treatment
Which drugs are you currently taking? How many are you taking?
Which drugs does she/he currently take? How many is she/he taking?
Current beliefs about medication
Why do you think you were prescribed this medical treatment? Are you aware of your treatment’s benefits? Which kind of advice would you like to receive regarding your medications?
Why do you think she/he was prescribed this medical treatment? Are you aware of the treatment’s benefits? Which type of information would you like to receive regarding these medications?
Previous experiences
Can you tell me which drugs you were taking before your stroke?
Do you know which drugs he/she was taking before the stroke?
Have you taken drugs before? How was your experience with your previous treatment? (benefits, side effects, over/under dosage)
Are you currently taking medications? And how is your experience with drugs? (benefits, side effects, over/under dosage)
Motivation
What motivates you to take your treatment?
In your opinion, what motivates medication adhesion?
Main barriers to medication adherence
What are the reasons for sometimes not taking your medication?
Daily treatment: how to help?
How do you manage your treatment? Do you need some help? (alarm reminders, nurse, caregiver, …)
Lifestyle changes
After your stroke diagnosis did you change your diet or lifestyle habits? Do you practice a sport regularly?
In your opinion, what diet and lifestyle habits changes are important after a stroke?
Healthcare (relationships with specialists, general practitioners, laboratory staff, pharmacist, nurses, …)
Do you think the organization of the healthcare system is appropriate?
Do you think the organization of the healthcare system is appropriate?
Relationships with the healthcare team (physician, pharmacist, nurse, physiotherapist, …)
How would you evaluate your relationships with the medical staff? Do you think it should be improved?
How would you evaluate your relationships with the medical staff? Do you think it should be improved?
Deep barriers mentioned by patients/caregivers
Reminders and reformulation of what was said… (= brief summary of the interview)
Reminders and reformulation of what was said… (= brief summary of the interview)
stroke. For healthcare professionals, the interview guide (table 2) was designed based on previously published methodologies [29, 33]. Each participant was informed of the study objectives and they all signed an informed consent form before the interview. The study was approved by the local ethics committee and registered with the French Data Protection Agency (CNIL) in February 2012.
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Data Analysis Each interview was recorded and ad verbatim transcriptions were provided. Some of them were presented in the results to illustrate the analysis. Transcripts were analyzed separately using an inductive approach. Discordances were solved by consensus. A manual data analysis was conducted based on three validated steps [34]: (1) condensing raw text data into a brief,
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Table 1. Guide to conduct the semi-structured interviews with patient or caregiver
Table 2. Guide to conduct the semi-structured interviews with health professionals
Main themes
Issues
Stroke, risk and recurrences
How do you think patients apprehend their disease? Do you systematically provide information? Do you think you provide enough information?
Define secondary preventive medication
Do you think you provide enough information on stroke medication? Do you talk about ‘secondary medication after stroke’? Do you use these exact words? How do you explain new treatments?
Current treatment
Do you advise patients on the proper use of medication or explain the pharmacology? Do you think patients follow your advices?
Motivation
What do you think are the motivations for patients to keep taking their medicines? How do you encourage them to take their medicines? Do you think stroke survivors are good compliers?
Treatment benefits
Do you believe that secondary prevention post stroke is helpful? Do you think patients understand the benefits of stroke treatments?
Main barriers to medication adherence
In your opinion, what are the reasons why patients do not take their medications? (listing of barriers to medication adherence)
Daily treatment: how to help?
Do you think patients need help managing their daily treatment? What would be good notions to be implemented?
Improving care
What do you think can be improved to increase compliance and facilitate drug taking?
Table 3. Characteristics of stroke survivors
Patient (n), Inpatient Age at time Time elapsed Stroke location gender (yes/no) of interview since stroke (years) (years, months)
Communication Medical treatment Caregiver disorders management at interviewed discharge (yes/no)
1, Male 2, Female 3, Female 4, Male 5, Female 6, Male 7, Male 8, Female 9, Male 10, Female 11, Male 12, Male 13, Male 14, Male
no no no no no dysarthria dysarthria no aphasia aphasia aphasia no aphasia no
66 63 40 67 52 48 38 53 56 78 40 63 66 57
2m 1m 4m 5y2m 1y1m 2m 2y3m 2y 1m 10 y 4 m 4y8m 4y7m 2m 5y8m
brainstem brainstem right hemisphere right hemisphere brainstem (laterobulbar) right hemisphere left hemisphere right hemisphere left hemisphere left hemisphere left hemisphere left hemisphere left hemisphere right hemisphere
patient patient patient patient patient patient patient patient caregiver caregiver caregiver caregiver caregiver caregiver
no no no no no no no no yes yes yes yes yes yes
Results
summarized format; (2) establishing clear links between the evaluation or research objectives and findings derived from raw data; (3) developing a framework for the underlying mechanisms of experiences, which are obvious in the raw data. The goal was to identify frequent, dominant or significant themes and keywords and categorize these findings according to the four research themes.
Participants Patients and Caregivers: 14 Interviews Characteristics of stroke survivors are presented in table 3. They were taking a mean of 9 different drugs (SD:
Medication Adherence for Stroke Patients: Barriers and Facilitators
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yes yes yes no no yes no no yes no no no yes no
Health professional
Number interviewed
Sex
Age, years
Resident (physician) Resident (physician) Physician MD, PhD Physician MD, PhD Senior nurse Nurses
1 1 1 1 1 7
male male male female female female
28 25 40 38 42 28 (23–35)*
* Mean (min–max).
4, range: 3–15), 79% of them had mobility impairments (hemiplegia) and 43% had speech disorders (aphasia, dysarthria). In average, each interview lasted about 22 min (SD: 4 min, range 16–30). Healthcare Professionals: 12 Interviews Four physicians and 8 nurses were interviewed. Characteristics are presented in table 4 and each interview lasted about 16 min (SD: 4 min, range 11–24). No subject refused to participate. Results are presented according to the four predetermined research themes. For healthcare professionals (P) = Physician, (N) = Nurse are indicated next to their quotes. Stroke Beliefs Patients Stroke came as a surprise for all patients, despite presenting many risk factors beforehand. ‘We don’t know where my stroke came from’, ‘it’s a little bit complicated’, ‘I never thought I would have a stroke’, ‘I did not expect it. I had no forewarning’. Caregivers Caregivers seemed to better understand the origins of the stroke and identified risk factors as ‘drinking, smoking and poor lifestyle habits’. They also widened their knowledge by doing an Internet search: ‘We looked on the Internet to find information on the disease and why we needed this treatment’. Healthcare Professionals Illness awareness depended on the patient’s profile and location of the stroke, that is, left or right side. ‘In patients with aphasia, illness awareness was impaired’ (P), ‘In patients with anosognosia, we repeat treatment rec266
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ommendations to no avail. It is more common for rightsided stroke patients’ (P). ‘Patients with aphasia have impaired speaking abilities. They might understand everything but cannot voice it’ (N). Healthcare professionals told us they were convinced they needed to adapt their speech to each patient or caregiver. ‘We tried explaining using words easily understandable by the patients and their family’ (P), ‘I repeat the information several times’ (P). Medications Issues Patients Stroke survivors were concerned with side effects of their medications: ‘Medications have more side effects than advantages’, ‘We treat the affected side, but the other side must bear the negative effects of the drugs’. They reported a lot of practical issues such as medication schedule or difficulties in taking the medications: ‘Should I take the drugs at set times?’, ‘It is not easy to cut the tablets in half’. They also voiced their fear of overmedication. ‘All these drugs are really strong’, ‘It is a low dose, perhaps I don’t need to be worried, but...’. Nevertheless, patients were aware of the absolute necessity of the treatment, in order to prevent a new stroke: ‘I have no choice; if I don’t take the medication, I will have a new stroke’, ‘I know I could die if I don’t take my medication’ …‘Of course remaining alive and well motivates me to take all these drugs’. Caregivers Similarly, caregivers also reported medication-related issues and concerns about generic drugs: ‘We concluded that it was a generic drug’, ‘Sometimes there are some problems with the pharmacy due to generic drugs’, ‘It has to be the real clopidogrel, not the generic drug, because sometimes they might give us another molecule, you never know’. They also feared overmedication: ‘The drugs they gave her were too strong, there are too many different types of drugs, and we can’t figure it out’. They were aware of the importance of treatment to prevent a new stroke: ‘I’m very serious with medications, I understand perfectly their impact on his life’. Healthcare Professionals Physicians were aware of not giving enough information on drug intake. ‘I don’t give out details about it’ (P), ‘We do not systematically inform the patients about precautions to be taken with this medication’ (P), ‘No, we don’t explain’ (N). According to physicians, a good time to deliver this information would be when they hand out Bauler et al.
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Table 4. Health professional characteristics
Patient Experience Patients Concerns about post-stroke changes were frequently reported by survivors, such as fear of recurrence: ‘Another one may happen’, ‘I could have another one and it scares me’. Lifestyle changes post-stroke were also brought up ‘We might need some time to get used to the condition’, ‘Our life will never be the same again’, ‘I told myself that things will no longer be ‘normal’. Concerning previous experience with drugs, all patients reported previous adverse events they had experienced: I experienced side effects with the drugs I took prior to the stroke: ‘diarrhea with metformin’, ‘insomnia with analgesics’, ...‘I had a lot of problems with medications’. Caregivers The impact of the first stroke is quite important and fear of recurrence is also expressed by caregivers: ‘We are still afraid of stroke recurrence’. They also brought up difficulties with these life changes. Furthermore, they expressed negative experience with the drugs ‘My mother had some issues with this medication before, so I am being careful’.
Relationships with Healthcare Professionals Patients They reported their relationships with healthcare professionals as ideal. ‘It went well’, ‘Perfect relationship with physicians and nurses’. Pharmacists are often well considered by patients, but only as they easily deliver the medications. ‘At the pharmacy: they do not need to give me advice since I come with a prescription’. Caregivers However, caregivers expressed divergent opinions about healthcare professionals. ‘We needed more information’, ‘Physicians have to be clearer’, ‘Their speech is too complicated and not adapted’. ‘We have a good relationship with our pharmacy. If we have a problem with renewing the prescription, they can easily give us one month treatment in advance’. Healthcare Professionals They all agreed on the need to deliver more information to their patients. ‘We should provide them with more information’ (P), ‘We should improve the way we deliver information on risks and recurrences’ (P). Caregivers are essential to the care management of stroke patient and thus need to be considered right from the beginning. ‘We have to involve the family’ (P). It is more difficult for patients to manage their treatment by themselves. The presence of family is a facilitator: ‘People with family or with a good social support have fewer difficulties in managing their treatment’ (N). Physicians also underline that patients will exhibit better treatment compliance with regular medical follow-up. ‘I insist that patients go to their family physician’ (P). They expressed that patients and caregivers need to trust their physician, it is essential in order to improve treatment compliance.
Discussion
Healthcare Professionals According to physicians and nurses, they do not often bring up the risk of recurrence with their patients. ‘We don’t talk about it, because they are already so anxious’ (N), ‘We explain it progressively and adapt our speech to each patient’ (P). They said that this issue is discussed only when patients exhibit a lot of risk factors, despite them being aware of the topic’s importance ‘They have to understand that they could have another stroke’ (N).
This is the first French qualitative study exploring the perceptions of stroke and secondary prevention treatments. Furthermore, this study is also original as it compares the perceptions of patients, caregivers and healthcare professionals.
Medication Adherence for Stroke Patients: Barriers and Facilitators
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Stroke Beliefs In our study, patients often had troubles understanding the objectives of post-stroke treatment. Conversely, caregivers were well aware of stroke risk factors and their 267
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the prescription to their patients. ‘I think that taking the time to explain the prescription to outpatients is really important’ (P). It is necessary to adapt the drug intake to the patient’s daily life. ‘Trying to decrease the number of different treatments, using a combination of drugs when possible …/… considering the patient’s preferences regarding galenic formulation’ (P), ‘Taking the time to discuss their medication schedule’ (P), ‘Since they cannot observe the effects of the drugs, they think them unnecessary’ (N). Healthcare professionals brought up the issue of not having clinical symptoms: ‘They do not feel sick so they think that if they do not take their medications they will not be sick. It’s a perverse reasoning’ (P), ‘Patients are tempted to stop taking their medications as they no longer exhibit clinical symptoms’ (N).
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liefs, communication around generics and their use [44]. Allenet et al., explored attitudes toward generics and three main elements that could explain them: (1) erroneous personal beliefs and knowledge and suspicion on the quality of the generics, (2) relationship with healthcare professionals and (3) previous experience with generics. So, communication around generics is essential to anticipate any resistance and adapt the prescription according to patients’ beliefs and preferences [42]. Patient Experience. Fear of stroke recurrence was also widely addressed during the interviews with patients and caregivers. Few studies have highlighted this element before. A study on antihypertensive drugs reported fear of complications as a facilitator for medication adherence. Nevertheless, fear of recurrence was not studied since it focused on primary prevention and no symptomatic cardiovascular event had happened [23]. Regarding stroke survivors, Chambers et al., showed that understanding the consequences of not taking the prescribed treatment led to better medication adherence. In our study, this appears to be a sensitive topic to discuss with patients [27] even though physicians agree that they do not discuss it often. Gale et al., reported that a patient’s attitude regarding medications depended on whether his or her condition was life-threatening and if medical treatment was the best and only therapeutic [40]. Stroke survivors need to adapt to their new life, yet caregivers’ lives are also impacted since patients often exhibit post-stroke motor impairments and need help. For caregivers, these difficulties of adapting to a ‘new’ life were previously reported [26, 45]. Rehabilitation focuses on the patient but caregivers have to be considered. Relationships with Healthcare Professionals. Our study reports good relationships between patients/caregivers and healthcare professionals. Nevertheless, patients generally evaluated the relationship as very good, while caregivers expressed divergent opinions. As previously described, caregivers should be considered more by healthcare teams [46], since they in turn support the patient [27, 47]. Caregivers seem to expect more from their family physician than patients [48], corroborating our results. In the present study, caregivers appreciate communicating with retail pharmacists. Conversely, patients do not think pharmacists should deliver advice and prefer talking to their doctor. Previous studies also found the same results: pharmacists are considered more like a drug supplier than a healthcare professional [23]. In order to ensure treatment compliance, it is essential to facilitate communication between patients, caregivers and healthcare professionals [26, 49] and improve partnerships between Bauler et al.
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involvement and support can help improve medication adherence in stroke patients. Healthcare professionals were aware that they needed to explain the origin of the stroke to their patients. Previous studies have highlighted the absence of knowledge regarding stroke and risk factors. Samsa et al., reported misconceptions in stroke survivors: 58% were unaware of their increased risk of having a subsequent stroke [35]. An Australian survey showed 50% of stroke survivors had insufficient knowledge based on a stroke knowledge score. Furthermore, stroke survivors were not more knowledgeable about the disease than non-stroke survivors [36]. For improving stroke knowledge in this population, it seems necessary to provide more information. Sullivan et al., reported the relevance of delivering educational pamphlets to provide more information through written educational material with other educational tools such as informative discussion and educational lectures [37]. Green et al., showed the impact of therapeutic patient education (TPE) interventions to increase knowledge in stroke survivors [38]. Corroborating these studies, Smith et al., validated the more effective interventions for improving knowledge were the ones that actively involved patients and caregivers and not the ones that only involved passive interventions [39]. In our study, stroke came as a surprise to all patients. As seen in the literature, patients have difficulties being aware of the severity of their illness when they exhibit no symptoms [23]. Medication Issue. In our study, patients and caregivers reported needing more information on drug intake (dosage, schedule and benefits/side effects). According to previous studies, healthcare professionals were also aware of not delivering enough practical information on drug intake. Gale et al., reported that family physicians were aware that they needed to explain what preventive medication was and its benefits [40] because patients did not take medication when they did not understand the benefits of a particular treatment [12, 41]. Furthermore, in the literature, stroke patients exhibited little knowledge on stroke medications and expressed concerns about side effects and fear of overmedication [12, 27]. In our study, contrary to healthcare professionals, caregivers expressed specific reservations about generic drugs; yet this issue was only rarely reported in the literature [42] but could represent a barrier for medication adherence. Previous studies reported the ambivalence of healthcare professionals concerning generic drugs, despite no validated evidence regarding differences in clinical outcomes between generics and brand-name drugs [43]. In fact, Shrank et al., showed a relationship between patients’ be-
hospital pharmacists and retail pharmacists and family physicians and specialists. Bushnell et al., reported better treatment compliance and better medication knowledge when patients had a scheduled appointment with their family physician upon discharge [9]. In previous studies, limited access to medication [3, 23, 24, 28] and inadequate healthcare system where reported as barriers for medication adherence affecting the relationship between patients and healthcare professionals. Since the French healthcare system allows free access to medication, it could explain why these issues were not reported here and probably do not constitute a major barrier for treatment compliance in French stroke survivors. Study Limits One limit of this study was that the patients and caregivers who were interviewed were not related to each other. It could have helped understand the changes in patient/caregiver relationship after stroke although that was not the objective of this work. Because of the small sample, it was impossible to compare the beliefs of nurses and physicians. Finally, medication adherence was not evaluated since some of the patients interviewed had just started their treatment. Consequently, we cannot formally validate a correlation between the beliefs expressed during the interviews and medication adherence.
Conclusion
Optimal medication adherence in stroke survivors is necessary for preventing recurrences. Taking into account beliefs from patients and caregivers, according to theoretical models of health-related behavior, is essential to reduce intentional non-adherence, often a consequence of erroneous representations. Our study was the first to specifically explore French beliefs surrounding medical treatments. Besides well-known barriers and facilitators for treatment compliance, our study showed new concerns about generic drugs and, contrary to popular belief, that the fear of stroke recurrence was actually a facilitator to medication adherence. These findings should be implemented into the future French educational programs.
Acknowledgments We would like to thank the patients, caregivers, nurses and physicians for having participated in this study and Bénédicte Clement for the translation of the manuscript.
Disclosure Statement None.
References
Medication Adherence for Stroke Patients: Barriers and Facilitators
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therapy on recurrent ischemic stroke and predictors of nonpersistence among ischemic stroke survivors. Curr Med Res Opin 2010;26: 1023–1030. Sjölander M, Eriksson M, Glader EL: The association between patients’ beliefs about medicines and adherence to drug treatment after stroke: a cross-sectional questionnaire survey. BMJ Open 2013;3:e003551, DOI: 10.1136/bmjopen-2013–003551. Bushnell C, Olson D, Zhao X, Pan W, Zimmer L, Goldstein L, Alberts MJ, Fagan SC, Fonarow GC, Johnston SC, Kidwell C, Labresh KA, Ovbiagele B, Schwamm L, Peterson ED; AVAIL Investigators: Secondary preventive medication persistence and adherence 1 year after stroke. Neurology 2011;77:1182–1190. Ji R, Liu G, Shen H, Wang Y, Li H, Peterson E, Wang Y: Persistence of secondary prevention medications after acute ischemic stroke or transient ischemic attack in Chinese population: data from China National Stroke Registry. Neurol Res 2013;35:29–36. Perreault S, Yu AYX, Côté R, Dragomir A, White-Guay B, Dumas S: Adherence to anti-
12
13
14
15
16
Eur Neurol 2014;72:262–270 DOI: 10.1159/000362718
hypertensive agents after ischemic stroke and risk of cardiovascular outcomes. Neurology 2012;79:2037–2043. O’Carroll R, Whittaker J, Hamilton B, Johnston M, Sudlow C, Dennis M: Predictors of adherence to secondary preventive medication in stroke patients. Ann Behav Med 2010; 41:383–390. Gadkari AS, McHorney CA: Unintentional non-adherence to chronic prescription medications: how unintentional is it really? BMC Health Serv Res 2012;12:98, DOI: 10.1186/ 1472–6963–12–98. Horne R, Weinman J: Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. J Psychosom Res 1999;47:555–567. Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X: Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2008;2:CD000011, DOI: 10.1002/14651858. Redfern J, McKevitt C, Wolfe CD: Development of complex interventions in stroke care: a systematic review. Stroke 2006; 37: 2410– 2419.
269
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/14/2015 3:05:34 AM
1 Haute Autorité de Santé: Prevention of stroke. Report. France, 2009. 2 Davis SM, Donnan GA: Clinical practice. Secondary prevention after ischemic stroke or transient ischemic attack. N Engl J Med 2012; 366:1914–1922. 3 World Health Organisation: Adherence to long-term therapies: evidence for action. Geneva, WHO, 2003. 4 Sappok T, Faulstich A, Stuckert E, Kruck H, Marx P, Koennecke HC: Compliance with secondary prevention of ischemic stroke. Stroke 2001;32:1884–1889. 5 Hamann GF, Weimar C, Glahn J, Busse O, Diener HC: Adherence to secondary stroke prevention strategies – results from the German Stroke Data Bank. Cerebrovasc Dis 2003;15:282–288. 6 De Schryver EL, Van Gijn J, Kappelle LJ, Koudstaal PJ, Algra A; for the Dutch TIA trial and SPIRIT study groups: Non-adherence to aspirin or oral anticoagulants in secondary prevention after ischaemic stroke. J Neurol 2005;252:1316–1321. 7 Burke JP, Sander S, Shah H, Zarotsky V, Henk H: Impact of persistence with antiplatelet
270
28 Schafheutle EI, Hassell K, Noyce PR, Weiss MC: Access to medicines: cost as an influence on the views and behaviour of patients. Health Soc Care Community 2002;10:187–195. 29 Williams AF, Manias E, Walker R: Adherence to multiple, prescribed medications in diabetic kidney disease: a qualitative study of consumers’ and health professionals’ perspectives. Int J Nurs Stud 2008;45:1742–1756. 30 Goff SL, Mazor KM, Meterko V, Dodd K, Sabin J: Patients’ beliefs and preferences regarding doctors’ medication recommendations. J Gen Intern Med 2008;23:236–241. 31 Yeung SM, Wong FKY, Mok E: Holistic concerns of Chinese stroke survivors during hospitalization and in transition to home. J Adv Nurs 2011;67:2394–2405. 32 White JH, Magin P, Attia J, Pollack MR, Sturm J, Levi CR: Exploring poststroke mood changes in community-dwelling stroke survivors: a qualitative study. Arch Phys Med Rehabil 2008;89:1701–1707. 33 Wens J, Vermeire E, Royen PV, Sabbe B, Denekens J: GPs’ perspectives of type 2 diabetes patients’ adherence to treatment: a qualitative analysis of barriers and solutions. BMC Fam Pract 2005, DOI: 10.1186/1471–2296–6– 20. 34 Thomas DR: A general inductive approach for analyzing qualitative evaluation data. Am J Eval 2006;27:237–246. 35 Samsa GP, Cohen SJ, Goldstein LB, Bonito AJ, Duncan PW, Enarson C, DeFriese GH, Horner RD, Matchar DB: Knowledge of risk among patients at increased risk for stroke. Stroke 1997;28:916–921. 36 Sullivan K, White K, Young R, Chang A, Roos C, Scott C: The nature and predictors of stroke knowledge amongst at risk elderly persons in Brisbane, Australia. Disabil Rehabil 2006;28:1339–1348. 37 Sullivan KA, Katajamaki A: Stroke education: retention effects in those at low- and high-risk of stroke. Patient Educ Couns 2009; 74: 205– 212. 38 Green T, Haley E, Eliasziw M, Hoyte K: Education in stroke prevention: efficacy of an educational counselling intervention to increase knowledge in stroke survivors. Can J Neurosci Nurs 2007;29:13–20.
Eur Neurol 2014;72:262–270 DOI: 10.1159/000362718
39 Smith J, Forster A, House A, Knapp P, Wright J, Young J: Information provision for stroke patients and their caregivers. Cochrane Database Syst Rev 2008;2:CD001919, DOI: 10.1002/14651858. 40 Gale NK, Greenfield S, Gill P, Gutridge K, Marshall T: Patient and general practitioner attitudes to taking medication to prevent cardiovascular disease after receiving detailed information on risks and benefits of treatment: a qualitative study. BMC Fam Pract 2011;12:59, DOI: 10.1186/1471–2296–12–59. 41 Clifford S, Barber N, Horne R: Understanding different beliefs held by adherers, unintentional nonadherers, and intentional nonadherers: application of the Necessity-Concerns Framework. J Psychosom Res 2008;64:41–46. 42 Allenet B, Golay A: What are patients’ attitudes towards generic drugs? The example of metformin. Rev Med Suisse 2013; 9: 1005– 1009. 43 Decollogny A, Eggli Y, Halfon P, Lufkin TM: Determinants of generic drug substitution in Switzerland. BMC Health Serv Res 2011; 11:17, DOI: 10.1186/1472–6963–11–17. 44 Shrank WH, Stedman M, Ettner SL, DeLapp D, Dirstine J, Brookhart MA, Fischer MA, Avorn J, Asch SM: Patient, physician, pharmacy, and pharmacy benefit design factors related to generic medication use. J Gen Intern Med 2007;22:1298–1304. 45 Jones L, Morris R: Experiences of adult stroke survivors and their parent carers: a qualitative study. Clin Rehabil 2013;27:272–280. 46 Cameron JI, Naglie G, Silver FL, Gignac MA: Stroke family caregivers’ support needs change across the care continuum: a qualitative study using the timing it right framework. Disabil Rehabil 2013;35:315–324. 47 Greenwood N, Mackenzie A, Harris R, Fenton W, Cloud G: Perceptions of the role of general practice and practical support measures for carers of stroke survivors: a qualitative study. BMC Fam Pract 2011;12:57, DOI: 10.1186/1471–2296–12–57. 48 Brotheridge S, Young J, Dowswell G, Lawler J, Forster A: A preliminary investigation of patient and carer expectations of their general practitioner in longer-term stroke care. J Eval Clin Pract 1998;4:237–241. 49 Eames S, Hoffmann T, Worrall L, Read S: Stroke patients’ and carers’ perception of barriers to accessing stroke information. Top Stroke Rehabil 2010;17:69–78.
Bauler et al.
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/14/2015 3:05:34 AM
17 Ovbiagele B, Saver JL, Fredieu A, Suzuki S, Selco S, Rajajee V, McNair N, Razinia T, Kidwell CS: In-hospital initiation of secondary stroke prevention therapies yields high rates of adherence at follow-up. Stroke 2004; 35:2879–2883. 18 O’Carroll RE, Chambers JA, Dennis M, Sudlow C, Johnston M: Improving adherence to medication in stroke survivors: a pilot randomised controlled trial. Ann Behav Med 2013;46:358–368. 19 Lummis H, Sketris I, Gubitz G, Joffres M, Flowerdew G: Medication persistence rates and factors associated with persistence in patients following stroke: a cohort study. BMC Neurol 2008;8:25, DOI: 10.1186/1471–2377– 8–25. 20 Sullivan KA, White KM, Young RM, Scott C: Predicting behaviour to reduce stroke risk in at-risk populations: the role of beliefs. Int J Ther Rehabil 2009;16:488–496. 21 Sullivan KA, White KM, Young RM, Chang A, Roos C, Scott C: Predictors of intention to reduce stroke risk among people at risk of stroke: an application of an extended health belief model. Rehabil Psychol 2008; 53: 505– 512. 22 Leventhal H, Diefenbach M, Leventhal EA: Illness cognition: using common sense to understand treatment adherence and affect cognition interactions. Cognitive Ther Res 1992; 16:143–163. 23 Tsiantou V, Pantzou P, Pavi E, Koulierakis G, Kyriopoulos J: Factors affecting adherence to antihypertensive medication in Greece: results from a qualitative study. Patient Prefer Adherence 2010;4:335–343. 24 Kronish IM, Diefenbach MA, Edmondson DE, Phillips LA, Fei K, Horowitz CR: Key barriers to medication adherence in survivors of strokes and transient ischemic attacks. J Gen Intern Med 2013;28:675–682. 25 Fried TR, Tinetti ME, Iannone L: Primary care clinicians’ experiences with treatment decision making for older persons with multiple conditions. Arch Intern Med 2011; 171: 75–80. 26 McKevitt C, Redfern J, Mold F, Wolfe C: Qualitative studies of stroke: a systematic review. Stroke 2004;35:1499–1505. 27 Chambers JA, O’Carroll RE, Hamilton B, Whittaker J, Johnston M, Sudlow C, Dennis M: Adherence to medication in stroke survivors: a qualitative comparison of low and high adherers. Br J Health Psychol 2011; 16: 592– 609.
