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      Barriers and facilitators to adherence to secondary stroke prevention medications after stroke: analysis of survivors and caregivers views from an online stroke forum

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          Abstract

          Objective

          To identify barriers and facilitators of medication adherence in patients with stroke along with their caregivers.

          Design

          Qualitative thematic analysis of posts about secondary prevention medications, informed by Perceptions and Practicalities Approach.

          Setting

          Posts written by the UK stroke survivors and their family members taking part in the online forum of the Stroke Association, between 2004 and 2011.

          Participants

          84 participants: 49 stroke survivors, 33 caregivers, 2 not stated, identified using the keywords ‘taking medication’, ‘pills’, ‘size’, ‘side-effects’, ‘routine’, ‘blister’ as well as secondary prevention medication terms.

          Results

          Perceptions reducing the motivation to adhere included dealing with medication side effects, questioning doctors’ prescribing practices and negative publicity about medications, especially in regard to statins. Caregivers faced difficulties with ensuring medications were taken while respecting the patient’s decisions not to take tablets. They struggled in their role as advocates of patient’s needs with healthcare professionals. Not experiencing side effects, attributing importance to medications, positive personal experiences of taking tablets and obtaining modification of treatment to manage side effects were facilitators of adherence. Key practical barriers included difficulties with swallowing tablets, dealing with the burden of treatment and drug cost. Using medication storage devices, following routines and getting help with medications from caregivers were important facilitators of adherence.

          Conclusions

          An online stroke forum is a novel and valuable resource to investigate use of secondary prevention medications. Analysis of this forum highlighted significant barriers and facilitators of medication adherence faced by stroke survivors and their caregivers. Addressing perceptual and practical barriers highlighted here can inform the development of future interventions aimed at improving adherence to secondary prevention medication after stroke.

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          Most cited references32

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          The influence of gender and age on disability following ischemic stroke: the Framingham study.

          Margaret Kelly-Hayes, Alexa S Beiser, Carlos Kase … (2007)
          The magnitude of disability among elderly stroke survivors is substantial. There have been few community-based estimates of the contribution gender and older age make to stroke-related disability and outcome. Using the original Framingham Study cohort, we documented gender-specific neurological deficits and disability differences in stroke survivors at six months post-stroke. Logistic regression analyses were performed to estimate odds ratios, comparing men and women, and adjusting for age, and age and stroke subtype. Age and gender-matched controls were then compared to distinguish stroke-related disability from disability associated with general aging. Results showed that almost half (43%) of all elderly stroke survivors in the cohort had moderate to severe neurological deficits. In the crude analyses, women were more dependent in ADLs (33.9% vs 15.6%), less likely to walk unassisted (40.3% vs 17.8%), and living in nursing homes (34.9 % vs 13.3%). After adjusting for age and stroke subtype, it was older age that accounted for the severity of disability. When compared to age and gender-matched controls, stroke cases were significantly more disabled in all domains studied. In this elderly cohort, more women experienced initial strokes and were more disabled at 6 months post-stroke than men. However, older age at stroke onset, not gender or stroke subtype, was associated with greater disability. Health care providers need to understand that strokes occur later in life for women and that because of age, women are at greater risk for disability and institutionalization.
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            How do we improve patient compliance and adherence to long-term statin therapy?

            Patricia Maningat, Bruce Gordon, Jan Breslow (2013)
            Statins are highly effective drugs prescribed to millions of people to lower LDL-cholesterol and decrease cardiovascular risk. The benefits of statin therapy seen in randomized clinical trials will only be replicated in real-life if patients adhere to the prescribed treatment regimen. But, about half of patients discontinue statin therapy within the first year, and adherence decreases with time. Patient, physician and healthcare system-related factors play a role in this problem. Recent studies have focused more on the patients' perspectives on non-adherence. Adverse events are cited as the most common cause of statin discontinuation; thus, the healthcare provider must be willing to ally and dialogue with patients to address concerns and assess the risks and benefits of continued statin therapy.
            Article 0 comments Cited 64 times – based on 0 reviews     Review now
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              Statins for secondary prevention in elderly patients: a hierarchical bayesian meta-analysis.

              Jonathan Afilalo, Gustavo Duque, Russell Steele … (2008)
              This study was designed to determine whether statins reduce all-cause mortality in elderly patients with coronary heart disease. Statins continue to be underutilized in elderly patients because evidence has not consistently shown that they reduce mortality. We searched 5 electronic databases, the Internet, and conference proceedings to identify relevant trials. In addition, we obtained unpublished data for the elderly patient subgroups from 4 trials and for the secondary prevention subgroup from the PROSPER (PROspective Study of Pravastatin in the Elderly at Risk) trial. Inclusion criteria were randomized allocation to statin or placebo, documented coronary heart disease, > or =50 elderly patients (defined as age > or =65 years), and > or =6 months of follow-up. Data were analyzed with hierarchical Bayesian modeling. We included 9 trials encompassing 19,569 patients with an age range of 65 to 82 years. Pooled rates of all-cause mortality were 15.6% with statins and 18.7% with placebo. We estimated a relative risk reduction of 22% over 5 years (relative risk [RR] 0.78; 95% credible interval [CI] 0.65 to 0.89). Furthermore, statins reduced coronary heart disease mortality by 30% (RR 0.70; 95% CI 0.53 to 0.83), nonfatal myocardial infarction by 26% (RR 0.74; 95% CI 0.60 to 0.89), need for revascularization by 30% (RR 0.70; 95% CI 0.53 to 0.83), and stroke by 25% (RR 0.75; 95% CI 0.56 to 0.94). The posterior median estimate of the number needed to treat to save 1 life was 28 (95% CI 15 to 56). Statins reduce all-cause mortality in elderly patients and the magnitude of this effect is substantially larger than had been previously estimated.
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Open
                Journal ID (iso-abbrev): BMJ Open
                Journal ID (hwp): bmjopen
                Journal ID (publisher-id): bmjopen
                Title: BMJ Open
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2044-6055
                Publication date Collection: 2017
                Publication date (Electronic): 16 July 2017
                Volume: 7
                Issue: 7
                Electronic Location Identifier: e016814
                Affiliations
                [1 ] departmentPrimary Care Unit, Department of Public Health and Primary Care, Forvie Site , University of Cambridge School of Clinical Medicine , Cambridge, UK
                [2 ] departmentCentre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry , Queen Mary University of London , London, UK
                Author notes
                [Correspondence to ] James Jamison; jj285@ 123456medschl.cam.ac.uk
                Article
                Publisher ID: bmjopen-2017-016814
                DOI: 10.1136/bmjopen-2017-016814
                PMC ID: 5541606
                PubMed ID: 28713074
                SO-VID: dff36abb-1e07-4917-8555-299cde720475
                Copyright © © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
                License:

                This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

                History
                Date received : 13 March 2017
                Date revision received : 17 May 2017
                Date accepted : 05 June 2017
                Funding
                Funded by: Stroke Association; British Heart Foundation;
                Categories
                Subject: Cardiovascular Medicine
                Subject: Research
                Subject: 1506
                Subject: 1683
                Custom metadata
                special-feature unlocked

                ScienceOpen disciplines: Medicine
                Keywords: ke,caregiver,medication adherence,online forum
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: ke, caregiver, medication adherence, online forum

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