15 A Toolkit for Health Care Professionals Unmet Needs in Hypertension Adherence barriers fall into five areas: Sociodemographic factors such as age, ethnicity, income and health literacy levels, housing stability, copayments, transportation, rural residency, social status and support, war and disasters. Health care factors such as patientclinician relationship, patient-centeredness, clinician’s communication style and ability, teambased care, qualitybased payment, access to care, cost of care and therapeutic inertia. Therapy factors such as complex treatment regimens, treatment changes, time to benefit, adverse effects, refill frequency and refill consolidation. Conditional factors particularly comorbidities such as depression, psychoses, drug or alcohol abuse, dementia, major disability, symptom severity and quality of life. Patient factors such as lack of knowledge/ misunderstanding, poor perception of hypertension and treatment effects, diagnosis denial, fear of dependence or adverse effects, forgotten doses, limited follow-up, low self-efficacy and use of alternative therapies.7-Table 2 1 2 3 4 5 Two general approaches can be used to screen for adherence: The 4Ps use patient questionnaires and self-reports, patient interviews, pill counting and prescription refill data. They are simple and inexpensive but are not necessarily reliable and cannot confirm ingestion of medication.6-Screening Methods The 4Ms use medication ingestion under observation, medication event monitoring systems (MEMS), medication level measurement in body fluids and a digital medicine. They are more reliable than the 4Ps but are more expensive and difficult to conduct in real-world clinical practice.6-Screening Methods Nonadherence is more prevalent among newly diagnosed patients with hypertension and is generally higher among young males of underrepresented race/ethnicity and in older people. However, sex race/ethnicity and age alone do not predict adherence. Population-level data show that racial/ethnic people who have lower income, less education and are publicly insured have similar BP control compared to those who are affluent, better educated and privately insured people.6-Contributing Factors of Medication Non-Adherance A practical approach to adherence addresses as many of the potential barriers to adherence as possible across all five areas. Adherence improves with better patient knowledge and appropriate perception of hypertension, especially if combined with satisfaction with clinic visits. Patient-centered strategies and nonjudgmental clinician communication are vital to adherence success. Tailoring interventions to individual patient needs is also important.6-Practical Approaches to Improve Medication Adherence
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