Medication Adherence in People of Culturally and Linguistically Diverse Backgrounds: A Meta-Analysis

964 n The Annals of Pharmacotherapy n 2010 June, Volume 44 theannals.com

Medication adherence involves theextent to which a person’s medica-

tion-taking behavior conforms to healthprofessionals’ advice. When people arenot adherent to their medications there isa greater likelihood that therapeuticgoals are not achieved, which leads to in-creased mortality and morbidity. Esti-mates for nonadherence range from 4%to 92%.1 Medication nonadherence costsapproximately $100 billion a year in theUS and leads to numerous, serious ad-verse events.2,3

The proportion of people of culturallyand linguistically diverse (CALD) back-grounds has always been relatively highin the US and other developed countries.In 2000, about 33% of the US popula-tion identified themselves as belongingto a racial or ethnic minority group. By2050, it is estimated that individuals ofCALD backgrounds will account for al-most half of the US population.4

Several studies have consistently de-monstrated that individuals of CALDbackgrounds have lower rates of medica-tion adherence than the general popula-tion.5-7 In a retrospective cohort study of56,561 people with hypertension and de-mentia, differences in medication adher-ence rates were observed for various drugclasses.5 Hispanic and African Americanpeople had significantly lower medication

Medication Adherence in People of Culturally and Linguistically

Diverse Backgrounds: A Meta-Analysis

Elizabeth Manias and Allison Williams

Adherence

Author information provided at end of text.

BACKGROUND: Medication adherence is of particular importance for people ofculturally and linguistically diverse (CALD) backgrounds due to languagedifficulties, lack of social and organizational supports, lack of access to health-care resources, and disengagement with the health-care system.

OBJECTIVE: To evaluate the impact of interventions to improve medicationadherence in people of CALD backgrounds through a systematic review andmeta-analysis.

METHODS: A search was performed using the following databases: CochraneDatabase of Systematic Reviews, Cumulative Index to Nursing & Allied HealthLiterature, EMBASE, Journals@Ovid, PsychInfo, PubMed, Science Direct,Scopus, and Web of Science. Databases were searched from January 1978 toOctober 2009.

RESULTS: Forty-six articles reviewed were assessed as being relevant, whichincluded 36 randomized controlled trials, 2 observational cohort studies, and 8quasi-experimental studies. The most common method for assessing medicationadherence was self-reporting measures, such as the Morisky Scale and itsmodifications. Few studies used combinations of adherence measures, andadherence involving a medication event monitoring system (MEMS) was used inonly 6 studies. Individuals of CALD backgrounds were recruited with people ofnon-CALD backgrounds and subsequent analyses tended to be undertaken ofthe whole sample. Twenty studies showed statistically significant improvementsin medication adherence, 15 of which were randomized controlled trials. Six ofthe successful interventions involved delivery by a bilingual person or the use oftranslated materials and 4 involved the use of a conceptual model. Meta-analyses demonstrated modest improvements in medication adherence.

CONCLUSIONS: Relatively little high-quality work has been conducted onadherence-enhancing interventions for people of CALD backgrounds. Greaterattention needs to be given to examining the needs of specific CALD populationgroups. Future researchers should consider rigorously testing interventions thattake into account the enormous diversity and differences that exist within anyparticular CALD group.

KEY WORDS: culturally and linguistically diverse background, intervention,medication adherence, meta-analysis, systematic review.

Ann Pharmacother 2010;44:964-82.

Published Online, 4 May 2010, theannals.com, DOI 10.1345/aph.1M572

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adherence rates (66% and 64%, respectively) compared withwhite people (69%) for the use of angiotensin-converting en-zyme inhibitors, acetylcholinesterase inhibitors (63% and60%, respectively, compared with 70%), and memantine(78% and 75%, respectively, compared with 83%).5 In aprospective cohort study of 122 patients with mental healthproblems, Hispanic and African American people had lowermedication adherence rates (77% and 68%, respectively) thanwhites (90%).6 In a case-control study of 764 people with dia-betes, multivariate analyses showed that black people weremore likely to demonstrate poor control of hemoglobin A1c,systolic blood pressure, low-density lipoprotein cholesterol,and total cholesterol levels due to missed medication doses(adjusted odds ratio 1.96) compared with white people (ad-justed odds ratio 1.13).7 Black people were also significantlymore likely than white people to report lack of knowledgeabout medication dose and purpose and difficulties with ask-ing health professionals about medication-related problems.7

The Agency for Healthcare Research and Quality hasregularly found that extensive health disparities, in terms ofquality of care and access to resources, continue to persist forindividuals of CALD backgrounds.4 In acknowledgment ofthese health disparities, the Office of Minority Health in theUS has released 14 National Standards on Culturally andLinguistically Appropriate Services (CLAS) to facilitate cul-turally competent care.8 In the US, it is expected that the stan-dards are integrated throughout organizations in partnershipwith the particular communities being served.

In considering the range of effects produced by inter-ventions addressing medication adherence on general popu-lations, a recent systematic review found that only small im-provements occurred and the results were inconsistent.9 Foracute conditions, 5 of 10 interventions showed an effect onmedication adherence while, for chronic conditions, 36 of 83interventions were associated with improved adherence. It isimportant to explore the nature of interventions involvingpeople of CALD backgrounds since the proportion of theseindividuals is increasing. Clearly, there is a need to educatethese individuals and health professionals about appropriateways to improve treatment outcomes. A major way toachieve this aim is to examine adherence interventions aimedspecifically at CALD populations.

The purpose of this study was to systematically reviewthe research literature and to conduct meta-analyses on in-terventions undertaken with people of CALD backgroundsto improve medication adherence.

Methods

DATA SOURCES AND SELECTION

Search Strategy

Databases searched included the Cochrane Database ofSystematic Reviews, Cumulative Index to Nursing & Allied

Health Literature, EMBASE, Journals@Ovid, PsychInfo,PubMed, Science Direct, Scopus, and Web of Science. Thesedatabases were searched from January 1978 to October 2009.The term culturally and linguistically diverse background isnot a recognized search term for several databases. A prelim-inary search of the National Library of Medicine was under-taken to determine appropriate MeSH terms to employ forthe review.10 The following MeSH terms were identified andused in combination for the search: ethnic groups, healthcaredisparities, medication adherence, cultural diversity, tran-sients and migrants, emigrants and immigrants, interventionstudies, and outcome assessment. Of the databases searched,MeSH terms are associated with PubMed; however, theseterms were helpful in identifying relevant and appropriate pa-pers in the other databases. The search results were limited toarticles published in English.

Inclusion and Exclusion Criteria

Controlled and uncontrolled, prospective and retrospec-tive, and randomized studies that had medication adher-ence as a primary or secondary outcome measure were ex-amined for the review. Patients were considered if theywere prescribed medication for an acute or chronic condi-tion. Caregivers who had responsibility in managing themedication needs of patients, such as parents of young chil-dren, were also considered. Only studies that involved eval-uation of an intervention of a psychosocial or educationalnature were examined. Examples of interventions assessedin studies included education (eg, information, feedback,mailed material), technology (eg, electronic timer devices),facilitators, scheduled appointments, home-based visits, tele-phone consultations, and support through disease self-man-agement. Thus, interventions that involved manipulations ofmedications, such as comparisons between once-daily ortwice-daily regimens, were not included. Interventionscould be directed at individuals or groups, and at patients orcaregivers. Studies were considered if they focused on peo-ple of CALD backgrounds in some way. For instance, theywere included if a model was used that involved CALDcharacteristics, the background involved some emphasis ofthe adherence problem existing in people of CALD back-grounds, there was targeted recruitment of individuals fromCALD backgrounds, the intervention addressed CALD is-sues, or the results involved analysis of CALD subgroups orcontrolled for these subgroups.

Articles were excluded if the research involved the merereporting of CALD group participation in the demograph-ics, without some acknowledgment of the particular needsof these people. Case studies and epidemiologic studiesthat did not involve the testing of an intervention were ex-cluded. Research disseminated through “gray” literaturesuch as conference papers and unpublished reports wasalso not considered.

The Annals of Pharmacotherapy n 2010 June, Volume 44 n 965theannals.com

Study Selection

We independently screened all abstracts identified in thesearch to create a group of potentially relevant studies. Thefull articles of all potentially relevant research were thenobtained and independently examined to determinewhether they met the inclusion criteria. References cited inpotentially relevant work and literature reviews were ex-plored for additional studies. If there was any uncertaintyor disagreement about whether certain studies met the in-clusion criteria, we arrived at a negotiated agreement.There was uncertainty or disagreement on 4 studies, whichwas easily resolved by negotiation.

Data Extraction

A structured data extraction form was developed fordocumenting information from each selected study. Thisinformation included the population studied, setting, sam-ple size, research design, type of intervention used, meth-ods used to assess adherence, main results, and signifi-cance of intervention. We independently extracted the dataand resolved any discrepancies through discussion.

Quality Ratings

Methodological quality was independently assessedbased on 8 criteria: (1) study design, (2) specification ofpatient sample, (3) power analysis, (4) specification of dis-ease, (5) specification of therapeutic regimen, (6) durationof follow-up, (7) definition of adherence, and (8) adher-ence measurement.11 Raw scores for the 8 criteria werecombined into an overall mean score standardized from 0to 100. When a discrepancy occurred, we discussed this is-sue to achieve resolution by a consensual process.

Meta-Analysis

Review Manager (RevMan, Cochrane Collaboration,version 5.1) was employed to conduct the meta-analyses,which were specified a priori using a random effects mod-el. Studies that provided results for control and interventiongroups and those that had either binary or continuous ad-herence outcomes following the conduct of a particular in-tervention were included. The Mantel-Haenszel risk ratiosummary estimate was used for studies that presented ad-herence outcomes as binary data, and the standardizedmean difference estimate was used for studies that present-ed adherence outcomes as continuous data. Separate meta-analyses were conducted on studies whose total samplepopulation comprised individuals from a CALD back-ground. Meta-analyses were carried out employing an in-tention-to-treat principle. Tests for heterogeneity were cal-culated, using χ2, τ2, and I2 tests. Forest plots were createdto illustrate the results graphically and to identify theweighting of each study. Findings with p values <0.05 and

95% confidence intervals that did not include 1.0 for riskratio estimates and did not include 0.0 for standardizedmean difference estimates were considered statistically sig-nificant.

Results

IDENTIFICATION AND SELECTION OF STUDIES

The initial literature search identified 994 abstracts fromwhich 72 full-text articles were retrieved for closer exami-nation according to the inclusion criteria. Twenty-six ofthese papers were excluded, mainly because the studies didnot involve the evaluation of an educational or psychoso-cial intervention or because they did not examine medica-tion adherence. In total, 46 studies met the inclusion crite-ria for the systematic review (Figure 1).

TYPES OF STUDIES AND SAMPLE CHARACTERISTICS

The final sample of 46 articles included 36 randomizedcontrolled trials,12-47 2 observational cohort studies,48,49 and8 quasi-experimental studies50-57 (Table 1). Sample sizesranged from 16 to 3456 participants and, apart from 2 stud-ies,36,50 all research was undertaken in the US. The percent-age of CALD groups participating as a proportion of thetotal sample ranged from 26% to 100%. The most com-mon chronic conditions targeted included hypertension (n= 14) and HIV (n = 12). Population groups involving thetreatment of acute conditions included parents and care-givers whose children were prescribed liquid medicationsafter attending an emergency department47 and motherswhose children were prescribed antibiotics for treatment of


E Manias and A Williams

Figure 1. Process used to identify relevant studies.

otitis media.38 In 2 studies, there was no focus on a particu-lar chronic or acute illness.22,57

INTERVENTIONS, FOLLOW-UP, AND METHODS OF

ADHERENCE

The selected studies included a variety of interventions(Table 2). Interventions were either multifaceted programs,testing the role of education in combination with psychoso-cial or behavioral initiatives, or provider-directed strategiessuch as the implementation of medication reviews. Meth-ods of delivery included pictorial instructions, handouts,DVDs, medication timer devices, telephone contacts,home visits, and group and individual discussion sessions.These interventions addressed health issues beyond the ac-tual ingestion of medications and involved aspects relatingto understanding and knowledge of the disease process andself-monitoring of symptoms.

Interventions were delivered either once23,34,37,38,47 or wereprovided over a number of sessions.12-22,24-33,35,36,39-46,50-52,54-56

The length of interventions tended to vary according to thechronic nature of the condition being treated, with thelongest interventions lasting 18 months.23 In some studiesthere was no information provided on the frequency orlength of the intervention delivered.48,49,53,57

The use of bilingual resources in an effort to addressspecific needs of people occurred at 3 levels: through abilingual assistant, delivery of written forms of communi-cation in intervention groups, and data collection tools(Table 2). A bilingual person delivered the intervention in18 studies, with Spanish being the most common languageused. Written aids used in interventions were translatedinto another language in 6 studies.19,38,41,47,52,55 In 2 studies,data collection tools were translated into Spanish.35,46

The length of the follow-up period is important to deter-mine sustainability of the intervention delivered.11 Follow-up varied from 1 month to 24 months after assessment ofbaseline measures. Some studies involved multiple timepoints for follow-up postintervention to facilitate more pre-cise evaluation of changes in outcomes over time (Table 2).

In 22 studies, medication adherence was the primary out-come (Table 2). Measures of adherence included self-reportof medication utilization,12-14,16-18,20,21,23-30,34,35,37,39-41,43,46,47,49-51,56

refill data or pharmacy records,13,17,37,42,43,52,53,57 pill counts orvolume measures,15,22,27,32,33,36,38,40,42,44,45,48,55 and the use of amedication event monitoring system (MEMS).19,30,31,35,39,55

In the work of Gerin et al.19 on adherence to antihyperten-sives, the authors tracked one “primary” antihypertensivethrough a MEMS measure based on past evidence that thisdrug was assumed to provide reliable data on all medica-tion-taking activity.58 A difficulty associated with relyingon 1 primary antihypertensive in utilizing the MEMS isthat it could limit valuable information gauged from alter-native antihypertensives or other medications.

The most common method for assessing medication ad-herence was self-reporting measures. The Morisky Scaleand its modifications were often used.12,17,23-25,27,28,40,51 Self-reporting measures for adherence were developed by someinvestigators, but little information was provided abouttheir validity and reliability.13,41,43 Bonner et al.14 used a 4-item family medication adherence scale with an alpha co-efficient measure of 0.65. Cooper et al.17 utilized the Hill-Bone Adherence Scale, which has been validated,59 whileSamet et al.35 used a validated, self-reported antiretroviraltherapy instrument. In attempting to corroborate data,Samet et al. found only a slight association between the30-day self-report data and MEMS data (intraclass corre-lation = 0.26, kappa = 0.19). In 2 studies, adherence to an-tiretroviral medication was measured using modified ques-tions from the Adults AIDS Clinical Trials Group Adher-ence Baseline Questionnaire, but no details were providedabout validation properties of these modified versions.20,56

Yin et al.47 assessed medication adherence through self-re-port by encouraging patients to keep a medication log oftheir administration. No details were given about patients’adherence in maintaining a log.

EFFECTIVENESS OF INTERVENTIONS

Twenty studies showed statistically significant improve-ments in medication adherence13-15,18,22,23,28,32,33,36,37,39,40,42,47,48,50-53;15 of these were randomized controlled trials. Variationswere sometimes found in intervention effectiveness de-pending on the type of adherence measure used. For in-stance, in the Berrien et al. study,13 medication adherencemeasured through refill frequency was substantially betterin the intervention group (mean refill score of 2.7 com-pared to 1.7 in the control group, p = 0.002); however, self-reported adherence to the medication regimen between the2 groups was not significant.

Individuals of CALD backgrounds were recruited along-side people of non-CALD backgrounds and subsequentanalyses were undertaken of the whole sample (Table 1).Subgroup analysis of intervention effectiveness was under-taken in 2 quasi-experimental studies55,57 and 1 randomizedcontrolled trial,24 2 of which showed improvements in ad-herence.24,57 For studies in which 100% of the sample werepeople of CALD backgrounds (n = 11), only 3 studiesshowed significant improvements in adherence.36,51,52 Six ofthe 20 successful interventions involved delivery by a bilin-gual person or the use of translated materials.13,14,28,47,52,53 In 16investigations involving the treatment of chronic conditions,there were no baseline measurements of adherence, whichmay lead to difficulties in determining the extent of impact ofthe intervention.14,15,18,23,25,31,32,36,39,41-43,45,46,48,49

Meta-analyses were completed on 21 studies with a di-chotomous outcome for adherence using the risk ratio ap-proach (Figure 2) and on 12 studies with a continuous out-

Medication Adherence in People of Culturally and Linguistically Diverse Backgrounds


https://www.researchgate.net/publication/8423403_Multicultural_medication_adherence_A_comparative_study?el=1_x_8&enrichId=rgreq-127e6fc6-8178-4eac-873c-33136f4c9a65&enrichSource=Y292ZXJQYWdlOzQ0NTczMDY2O0FTOjEwMTk5ODI5MjYzNTY1MUAxNDAxMzI5Njk2MTkx

https://www.researchgate.net/publication/7925875_Impact_of_an_adherence_clinic_on_behavioral_outcomes_and_virologic_response_in_treatment_of_HIV_infection?el=1_x_8&enrichId=rgreq-127e6fc6-8178-4eac-873c-33136f4c9a65&enrichSource=Y292ZXJQYWdlOzQ0NTczMDY2O0FTOjEwMTk5ODI5MjYzNTY1MUAxNDAxMzI5Njk2MTkx



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ctor

ialt

rial

Mor

isky

RC

Tw

ith4-

grou

pU

SA

dole

scen

tson

anti-

tube

rcul

osis

med

icat

ion

Inte

rven

tion

1:19

9,96

.9%

15.2

516

mo

/6,1

2m

o(2

001)

24de

sign

Asi

an,A

fric

anA

mer

ican

(oth

ers:

whi

te,N

R)

Inte

rven

tion

2:20

4,96

.6%

15.4

50In

terv

entio

n3:

196,

93.9

%15

.253

Con

trol

:195

,93.

9%15

.452

Mor

isky

RC

Tw

ith4-

grou

pU

SH

yper

tens

ion

1367

53.5

(no

brea

kdow

n)41

(no

brea

kdow

n)10

min

(for

1in

terv

entio

n,ot

hers

(200

2)25

desi

gnH

ispa

nic,

blac

k(o

ther

s:N

R)

98%

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brea

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n)N

R)

/6,1

2m

o

Mur

phy

RC

TU

SA

dults

,HIV

-pos

itive

orA

IDS

17/1

639

(no

brea

kdow

n)88

(no

brea

kdow

n)7

wk

/7w

k,(2

002)

26B

lack

,Afr

ican

Am

eric

an,L

atin

o,H

ispa

nic,

Asi

an,

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brea

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n)5

mo

Pac

ific

Isla

nder

(oth

ers:

whi

te)

Oge

degb

eR

CT

US

Hyp

erte

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n95

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(no

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Am

eric

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(200

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His

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c(o

ther

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hite

,NR

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%/7

1%

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Type

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4060

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95/9

912

mo

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mo

(200

1)29

Bla

ck,H

ispa

nic

(oth

ers:

whi

te,N

R)

46%

/34%

Rat

hbun

RC

TU

SH

IV-p

ositi

ve,o

nH

AA

RT

16/1

738

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75/9

412

wk

/4,1

6,28

wk

(200

5)30

Bla

ck,H

ispa

nic

(oth

ers:

whi

te)

26%

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lings

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linic

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3)31

tria

lA

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anA

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ican

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pani

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ers:

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te,

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der

RC

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SH

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tens

ion

Inte

rven

tion

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980)

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ers:

whi

te)

Inte

rven

tion

2:25

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51.3

32In

terv

entio

n3:

25,1

00%

4928

Con

trol

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Res

nick

Pre

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tU

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lder

ly(≥

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erte

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nor

hype

rlipi

dem

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76.4

/NA

36/N

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wk

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(200

9)54

inte

rven

tion,

Afr

ican

Am

eric

an10

0%si

ngle

grou

p

Ric

hR

CT

US

CH

F14

2/1

4080

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8.4

32/4

190

days

/90

days

(199

5)33

Bla

ck,A

sian

(oth

ers:

whi

te)

48%

/41%

Rob

bins

Pre

-pos

tU

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omen

,ost

eopo

rosi

s10

973

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A12

mo

/3,6

,9,1

2m

o(2

004)

55in

terv

entio

nH

ispa

nic,

blac

k(o

ther

s:w

hite

)47

.7%

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ren

RC

TU

SH

IV-p

ositi

ve30

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40.8

(no

brea

kdow

n)88

(no

brea

kdow

n)1

sess

ion

/2,1

2w

k(2

001)

34A

fric

anA

mer

ican

,His

pani

c,La

tino

(oth

ers:

whi

te,

58%

(no

brea

kdow

n)N

R)

Sam

etR

CT

US

HIV

infe

ctio

n,al

coho

lpro

blem

s74

/77

42.5

/43.

278

/84

3m

o/1

,2,3

,6,1

2,13

mo

(200

5)35

His

pani

c,bl

ack

(oth

ers:

whi

te)

66%

/74%

Sau

nder

sR

CT

Sou

thH

yper

tens

ion

56/5

940

–59

(~65

%)

30/3

46

mo

/6m

o(1

991)

36A

fric

aU

rban

blac

kS

outh

Afr

ican

100%

Sch

affe

rR

CT

US

Ast

hma

Inte

rven

tion

1:10

37(n

obr

eakd

own)

33(n

obr

eakd

own)

30–6

0m

in/3

mo,

6m

o(2

004)

37A

fric

anA

mer

ican

,His

pani

c,A

sian

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ific

Isla

nder

Inte

rven

tion

2:12

(oth

ers:

whi

te)

Inte

rven

tion

3:11

Con

trol

:13,

28%

(no

brea

kdow

n)

CA

LD=

cultu

rally

and

lingu

istic

ally

dive

rse;

CH

F=

cong

estiv

ehe

artf

ailu

re;C

OP

D=

chro

nic

obst

ruct

ive

pulm

onar

ydi

seas

e;H

AA

RT

=hi

ghly

activ

ean

tiret

rovi

ralt

hera

py;N

A=

nota

pplic

able

;NR

=no

trep

ort-

ed;R

CT

=ra

ndom

ized

cont

rolle

dtr

ial.

a Fol

low

-up

perio

dsre

late

totim

efr

omth

epo

into

fass

essm

ento

fbas

elin

em

easu

res.

(con

tinue

don

page

970)



Tabl

e1.

Cha

ract

eris

tics

ofS

tudi

eson

Inte

rven

tions

toIm

prov

eA

dher

ence

inP

eopl

eof

CA

LDB

ackg

roun

ds(c

ontin

ued)

Inte

rven

tio

n/

Co

ntr

ol(

n)

Mea

nA

ge

(y)

Sex

(%m

ale)

CA

LD

Inte

rven

tio

n/

Inte

rven

tio

n/

Inte

rven

tio

n/

Ref

eren

ceD

esig

nC

ou

ntr

yP

op

ula

tio

nB

ackg

rou

nd

(%)

Co

ntr

ol

Co

ntr

ol

Fo

llow

-Up

a

Sch

war

tz-L

ooki

nlan

dR

ando

miz

ed,

US

Mot

her-

child

coup

lets

,acu

teot

itis

med

ia31

/31

Mot

hers

:24

/25.

6M

othe

rs:N

A10

min

/10

days

(198

9)38

post

-tes

tonl

y,H

ispa

nic

100%

Chi

ldre

n:2.

5/2

.7C

hild

ren:

NR

cont

rolle

dgr

oup

desi

gn

Sm

ith(2

003)

39R

CT

US

HIV

orA

IDS

22/2

137

(no

brea

kdow

n)77

/81

3m

o/3

mo

Bla

ck(o

ther

s:w

hite

)68

.1%

/80.

9%

Sol

omon

(199

8)40

RC

TU

SH

yper

tens

ion

orC

OP

DH

yper

tens

ion

66.3

/67.

398

/93

6m

o/6

mo

Bla

ck,A

sian

,His

pani

c,La

tino

(oth

ers:

whi

te,N

R)

63/7

0,38

.1%

/34.

3%C

OP

D69

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9.3

100

/100

43/5

5,9.

3%/1

6.4%

Telle

s(1

995)

41R

CT

US

Low

inco

me,

schi

zoph

reni

a42

30(n

obr

eakd

own)

64(n

obr

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own)

12m

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oM

exic

an,G

uate

mal

an,S

alva

dora

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0%(n

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van

Ser

velle

n(2

003)

56Q

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erim

enta

l,U

SH

IVin

fect

ion

41/4

041

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9.6

88/9

35

wk

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ore

peat

edLa

tino

100%

mea

sure

s

Vel

ligan

(200

8)42

RC

TU

SS

chiz

ophr

enia

Inte

rven

tion

1:32

,61.

3%40

439

mo

/3,6

,9,1

2,15

mo

Afr

ican

Am

eric

an,H

ispa

nic

(oth

ers:

whi

te,N

R)

Inte

rven

tion

2:34

,70.

6%37

65C

ontr

ol:2

9,55

.2%

3962

Viv

ian

(200

2)43

RC

TU

SH

yper

tens

ion

27/2

964

/65.

510

0/1

006

mo

/6m

oA

fric

anA

mer

ican

(oth

ers:

whi

te,N

R)

85.1

%/6

9%

Wal

ker

(200

0)44

RC

TU

SH

yper

tens

ion

43/4

048

–98

(no

brea

kdow

n)13

(no

brea

kdow

n)6

wk

/3m

oA

fric

anA

mer

ican

100%

Web

b(1

980)

45R

CT

US

Hyp

erte

nsio

n,lo

win

com

e,ru

ralb

ackg

roun

dIn

terv

entio

n1:

3755

.519

3m

oB

lack

Inte

rven

tion

2:31

55.7

239

wk

/1,2

,3m

oC

ontr

ol:5

5,10

0%55

.522

Wes

tber

g(2

005)

57P

re-p

ost

US

Pha

rmac

ycu

stom

ers

9126

–55

(n=

45)

47/N

AN

R/1

0m

oin

terv

entio

nV

ietn

ames

e,H

mon

g,La

otia

n,S

omal

i,S

pani

sh,

71%

56–6

5(n

=37

)C

ambo

dian

,Nat

ive

Am

eric

an,A

fric

an66

–85

(n=

21)

Am

eric

an,A

fric

an(o

ther

s:E

urop

ean

Am

eric

an)

Wya

tt(2

004)

46R

CT

US

Wom

en,H

IV-p

ositi

ve67

/80

39(n

obr

eakd

own)

NA

11w

k/1

1w

k,3,

6m

oLa

tina,

Afr

ican

Am

eric

an(o

ther

s:E

urop

ean

93.9

%A

mer

ican

)

Yin

(200

8)47

RC

TU

SC

areg

iver

s,ch

ildre

non

liqui

dm

edic

atio

ns12

4/1

21C

areg

iver

s:31

.1/2

9.6

13/7

1.5–

3m

in/3

–5da

ysA

sian

,Nat

ive

Haw

aiia

n,P

acifi

cIs

land

er,

97.6

%/9

5.9%

Chi

ldre

n:3.

7/3

.452

/64

Latin

obl

ack,

Nat

ive

Am

eric

an,A

mer

ican

Indi

an,A

lask

anN

ativ

e(o

ther

s:w

hite

,NR

)

CA

LD=

cultu

rally

and

lingu

istic

ally

dive

rse;

CH

F=

cong

estiv

ehe

artf

ailu

re;C

OP

D=

chro

nic

obst

ruct

ive

pulm

onar

ydi

seas

e;H

AA

RT

=hi

ghly

activ

ean

tiret

rovi

ralt

hera

py;N

A=

nota

pplic

able

;NR

=no

trep

ort-

ed;R

CT

=ra

ndom

ized

cont

rolle

dtr

ial.

a Fol

low

-up

perio

dsre

late

totim

efr

omth

epo

into

fass

essm

ento

fbas

elin

em

easu

res.

come for adherence using the standardized mean differ-ence approach (Figure 3). It was not possible to undertakemeta-analysis on 6 studies for which no control group waspresent,49,52-55,57 on 4 studies for which no clear adherenceresults were provided for control and intervention groupsfollowing conduct of the intervention,20,25,41,45 and on 3studies that related to ongoing research.17,19,27

For the meta-analysis involving studies with dichotomousoutcomes, the random effects model using the Mantel-Haen-szel summary estimate was statistically significant with a riskratio of 0.75 for adherence (95% CI 0.67 to 0.85). The χ2 testfor heterogeneity was 129.49, which was significant at p <0.001, while the τ2 and I2 results were 0.05% and 85%, re-spectively (Figure 2). For the meta-analysis involving studieswith continuous adherence outcomes, the random effectsmodel using the standardized mean difference was statistical-ly significant, with a value of –0.71 for adherence (95% CI–1.17 to –0.26). The χ2 test for heterogeneity was 80.61,which was significant at p < 0.001, while the τ2 and I2 resultswere 0.52% and 86%, respectively (Figure 3).

Two separate meta-analyses were undertaken on a totalof 7 studies where 100% of the participants came from aCALD background: 1 meta-analysis involved studies usinga dichotomous adherence measure (n = 5), while the otherinvolved studies using a continuous adherence measure (n= 2). For the meta-analysis relating to studies involving adichotomous adherence outcome, the random effects mod-el was not statistically significant, with a risk ratio of 0.81for adherence (95% CI 0.63 to 1.04). For the meta-analysisinvolving studies that employed a continuous adherencemeasure, the random effects model was not significant,with a standardized mean difference of –0.22 for adher-ence (95% CI –1.01 to 0.57).

MODELS GUIDING INTERVENTIONAL WORK

No mention was made about a model to guide the re-search process in 34 studies (Table 2). The Health BeliefModel and Motivational Theory were the most commonmodels employed and, in some studies, combinations ofmodels were used. Four of the 20 studies demonstratingsignificant improvements in medication adherence in-volved the use of a model.13,14,37,39

QUALITY OF STUDIES

Table 3 shows an overview of the quality of the inter-ventional studies reviewed. Of the 46 studies, there was nopower analysis reported in 38. Loss of participant follow-upvaried extensively, ranging from 1% to 51%. Reasons forloss to follow-up were mentioned in 29 studies. Lack ofblinding of the outcome assessor was an issue for 10 studiesand, in 11 studies, no mention was made of whether blindingoccurred. Mean quality percent scores for all studies were

completed using the method described by Nichol et al.11 Of46 studies, 23 had a mean percent quality score >60%.

Discussion

Despite the critical issue of medication adherence inpeople of CALD backgrounds, relatively little high-qualitywork has been conducted on adherence-enhancing inter-ventions. A range of interventions were identified in the re-view with modest efficacy in improving adherence. Manystudies were of variable methodological quality due tosmall sample sizes, lack of power analysis, lack of a blind-ed outcome assessor, and insufficient description or choiceof adherence measures.11

Despite the espoused benefits of using models based oncognitive therapy, behavioral modification, and motiva-tional interviewing in developing tailored interventions formedication adherence,60,61 the majority of studies lacked astrong theoretical basis. Of the studies that involved use ofa model, much of the emphasis was based on explicatingcurrent literature relating to people of CALD backgroundsor in developing culturally specific interventions. Con-versely, models were generally not considered in interpret-ing results of interventions or in refining attributes of inter-ventions to make them more specific to the needs of indi-viduals from CALD backgrounds. Considering the lack ofwork in this area, more tailored interventions informed byvalidated models are warranted.

Many studies lacked adequate clarification of the natureand content of interventions provided. In some studies,there were no details about the duration of interventions orabout the frequency of contact with participants. This situ-ation makes it very difficult for future investigators to re-produce, build upon, and refine interventions used in pastresearch. Interventions tended to focus on increasing par-ticipants’ knowledge about medications as the means bywhich to improve medication adherence. However, pastwork has consistently shown that education alone does notlead to shifts in medication adherence.61,62 Our review hasalso demonstrated that using just bilingual people andtranslated resources in interventions is not sufficient for en-hancing medication adherence.

Past research has demonstrated links between communi-cation difficulties, patient decision making, and medicationadherence.60 People of ethnic minority backgrounds havebeen shown to be less verbally expressive, less affective, andless assertive in their decision making and interactions withphysicians, compared with other patients.62 Communicationstyles are influenced by culture, and for some cultures, peo-ple’s communication styles can make it challenging for themto pose questions to health professionals, which in turn canlead to a lack of effective information exchange and under-standing that facilitates poor medication adherence.7 In con-sidering the US-based interventions aimed at improving





Tabl

e2.

Inte

rven

tions

and

Adh

eren

ceM

easu

rem

ents

a

Sig

nif

ican

tP

rim

ary

Co

ntr

ol

Dif

fere

nce

sR

efer

ence

Inte

rven

tio

nan

dT

heo

reti

calM

od

elA

dh

eren

ceM

easu

rem

ent

Ou

tco

me

Inte

rven

tio

nG

rou

pG

rou

p(p

<0.

05)

Arm

our

9-m

opr

ogra

mde

liver

edby

com

mun

ityph

arm

acis

tsR

isk

ofno

nadh

eren

ce,5

-item

subs

cale

HbA

1cR

isk

ofno

nadh

eren

ce(2

004)

50M

odel

NR

ofB

riefM

edic

atio

nQ

uest

ionn

aire

base

line:

3.89

2.81

No

(ran

ge0–

7,7

=no

adhe

renc

e)9

mo:

2.74

3.90

Yes

Bab

amot

oIN

T1:

com

mun

ityhe

alth

wor

ker,

10-w

kdi

abet

esed

ucat

ion

Sel

f-re

port

:Mor

isky

Sel

f-R

epor

ted

HbA

1c,B

MI

Nev

erfo

rget

tota

kedi

abet

es(2

009)

12pr

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mby

bilin

gual

wor

kers

and

follo

w-u

pph

one

calls

Med

icat

ion

Beh

avio

rS

cale

med

icat

ions

,%ov

er6

mo

base

line

INT

2:ca

sem

anag

emen

t,m

onth

lyca

reby

nurs

esIN

T1:

6967

No

Tran

sthe

oret

ical

mod

elIN

T2:

7767

No

6m

oIN

T1:

7950

Yes

INT

2:55

50Ye

s

Ber

rien

8st

ruct

ured

hom

evi

sits

over

3m

o,ed

ucat

ion

onkn

owle

dge

Sel

f-re

port

:37

item

sde

velo

ped

byA

dher

ence

Sel

f-re

port

(200

4)13

and

unde

rsta

ndin

gof

dise

ase

and

med

icat

ions

;Spa

nish

-au

thor

s(s

core

0–37

);ph

arm

acy

base

line:

32.2

31.7

No

spea

king

case

man

ager

avai

labl

eto

inte

rven

tion

grou

pre

fillr

ecor

ds(s

core

0–3)

3m

o:34

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oH

ealth

Bel

iefM

odel

Ref

illre

cord

sba

selin

e:N

RN

RN

R3

mo

(mea

n):2

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7Ye

s

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ner

3gr

oup

educ

atio

nw

orks

hops

cond

ucte

dat

1-m

oin

terv

als

Sel

f-re

port

:4-it

emfa

mily

adhe

renc

eK

now

ledg

eP

resc

ribed

freq

uenc

y%

(200

2)14

over

3m

o,de

liver

edby

fam

ilyco

ordi

nato

rflu

enti

nS

pani

shsc

ale

deve

lope

dby

auth

ors;

αab

outa

sthm

aba

selin

e:N

RN

RN

Ran

dE

nglis

hin

tern

alco

nsis

tenc

y=

0.67

3m

o:82

40Ye

sA

sthm

aS

elf-

Reg

ulat

ion

Mod

el

Bur

relle

Atte

ndan

ceat

Trea

tmen

tInf

orm

atio

non

Med

icat

ions

for

the

Pill

coun

tsA

dher

ence

Pill

coun

ts%

(198

6)15

Eld

erly

prog

ram

over

8w

kba

selin

e:N

RN

RN

RM

odel

NR

8w

k:92

71Ye

s

Can

ino

8as

thm

aed

ucat

ion

mod

ules

deliv

ered

durin

g2

hom

evi

sits

Sel

f-re

port

ofus

eof

resc

uean

dm

aint

e-S

ympt

om-f

ree

Bas

elin

e:67

.360

.4N

o(2

008)

16an

dte

leph

one

cont

acts

over

~18

days

nanc

edr

ugs;

drug

sbr

ough

tto

clin

icda

ys4

mo:

64.8

64.6

No

Mod

elN

R

Coo

per

20-m

inco

achi

ngbe

fore

phys

icia

nvi

sit,

10-m

inde

brie

fing

App

oint

men

tkee

ping

,pha

rmac

yre

cord

s,A

dher

ence

NA

NA

NA

(200

9)17

sess

ion,

10-

to15

-min

tele

phon

eca

llsat

2w

kan

d3,

6,se

lf-re

port

(Hill

-Bon

eA

dher

ence

Sca

le),

9,12

mo

post

base

line;

com

mun

icat

ion

skill

sC

D-R

OM

prov

ider

repo

rtpr

ogra

mfo

rph

ysic

ians

Mod

elN

R

Dilo

rio3

mot

ivat

iona

lint

ervi

ewin

gse

ssio

ns,2

wk

apar

t;m

otiv

atio

nal

Sel

f-re

port

ofm

isse

dm

edic

atio

nsin

past

Adh

eren

ceB

asel

ine:

NR

NR

NR

(200

3)18

and

educ

atio

nalm

ater

ials

2w

kan

d30

days

,Ant

iretr

ovira

lGen

eral

AG

AS

mea

n,8

wk:

26.5

23.4

4N

oM

odel

NR

Adh

eren

ceS

cale

(pos

sibl

esc

ore:

5–30

)M

isse

dm

edic

atio

nsin

0.70

No

past

2–8

wk:

0.06

Abi

lity

tota

kem

edic

atio

nin

past

33.3

%Ye

s30

days

–8w

k:87

.5%

Fer

nand

ez6

wee

kly

and

2m

onth

lygr

oup

sess

ions

Sel

f-re

port

(Mor

isky

Sca

le);

adhe

rent

ifS

ysto

lican

dB

asel

ine:

24%

59%

Yes

(200

8)51

Mod

elN

Rre

spon

ded

“no”

toal

lite

ms

dias

tolic

BP

6w

k:56

%36

%Ye

sch

ange

14w

k:52

%58

%N

o

Ger

inM

onth

ly5-

min

tele

phon

eca

llsfo

r12

mo,

self-

mon

itorin

gof

ME

MS

ofpr

imar

ym

edic

atio

non

lyS

ysto

licB

PN

AN

AN

A(2

007)

19B

P;a

llst

udy

mat

eria

lsav

aila

ble

inS

pani

shan

dE

nglis

h;ca

sem

anag

ers

and

recr

uite

rsw

ere

Eng

lish-

and

Spa

nish

-sp

eaki

ngM

odel

NR



Hirs

chP

rovi

sion

ofm

edic

atio

nth

erap

ym

anag

emen

tby

com

mun

ityP

illco

unts

Adh

eren

ceB

asel

ine:

notc

ondu

cted

notc

ondu

cted

NA

(200

9)48

phar

mac

ies

topt

s.w

ith≥5

0%pr

escr

iptio

nsfil

led

at24

mo:

56.3

%38

.1%

Yes

phar

mac

yov

er2

yM

odel

NR

Jone

s10

wee

kly

2-h

sess

ions

ofco

gniti

ve-b

ehav

iora

lstr

ess

Sel

f-re

port

(14-

item

Adh

eren

ceto

Adh

eren

ceB

asel

ine:

68%

mea

nad

here

nce

NA

(200

3)20

man

agem

ent

Med

icat

ion

Sca

le(a

dapt

edfr

omA

CT

Gco

mbi

ned

resu

ltM

odel

NR

Que

stio

nnai

refo

rA

dher

ence

toA

nti-

10w

k:lo

w-a

dher

entp

ts.(

≤80%

19.6

%in

crea

seYe

s:w

ithin

-gro

upH

IVM

edic

atio

n)ad

here

nce)

:30.

4%in

crea

sein

inad

here

nce

for

inte

rven

tion

adhe

renc

eN

o:w

ithin

-gro

upfo

rco

ntro

lN

oco

mpa

rison

betw

een

grou

ps

Krie

rC

ouns

elin

gby

cert

ified

diab

etes

educ

ator

ever

y3

mo

for9

mo

Sel

f-re

port

onad

here

nce

usin

g4-

poin

tA

dher

ence

toB

asel

ine:

1.7

2.1

No

(199

9)21

Mod

elN

RLi

kert

scal

e(1

=ve

ryad

here

ntto

4=

follo

w-u

p3

mo:

1.8

2.3

No

nota

dher

ent)

visi

ts6

mo:

1.8

2.0

No

HbA

1cle

vels

9m

o:1.

51.

6N

o

Lai(

2007

)529-

mo

com

mun

ityph

arm

acy-

base

dhy

pert

ensi

ondi

seas

eM

edic

atio

nre

fills

Sys

tolic

and

Bas

elin

e:70

.6%

NA

NA

man

agem

entp

rogr

am;a

llor

alan

dw

ritte

nco

mm

unic

atio

ndi

asto

licB

P1

mo:

71.2

%N

oin

Spa

nish

chan

ge3

mo:

82.7

%Ye

sM

odel

NR

6m

o:88

.5%

Yes

9m

o:95

.8%

Yes

(com

pari-

sons

with

base

line

ofin

terv

entio

ngr

oup)

Lam

Med

icat

ion

cons

ulta

tions

from

phar

mac

ists

Sel

f-re

port

edus

eof

med

icat

ions

inS

ysto

lican

dB

asel

ine:

NR

NA

NA

(200

8)49

Mod

elN

Rph

arm

acy

reco

rds

dias

tolic

BP

6m

o:11

4ad

here

nce

prob

lem

sN

AN

R(w

ithin

-gro

upch

ange

iden

tifie

din

258

pts.

com

paris

on)

Leal

Pha

rmac

ist-

base

ddi

seas

est

ate

man

agem

ents

ervi

cew

ithP

harm

acy

reco

rds;

adhe

renc

eba

sed

BP

cont

rol

Bas

elin

e:12

7/44

6(2

8.5%

)N

AN

A(2

008)

53a

bilin

gual

,cer

tifie

ddi

abet

esed

ucat

oron

num

ber

ofpt

s.on

3dr

ugs

(asp

irin,

Fol

low

-up

(dat

eN

R):

281/

446

Yes

(with

in-

Mod

elN

RA

CE

inhi

bito

r,st

atin

)(6

3.0%

)gr

oup

com

paris

on)

Lee

Pro

spec

tive

obse

rvat

iona

lpha

se:6

mo

ofin

divi

dual

ized

Pill

coun

tsA

dher

ence

Bas

elin

e(p

hase

1,ru

n-in

phas

e):

NA

NA

(200

6)22

educ

atio

n,dr

ugdi

spen

sed

inbl

iste

rpa

cks,

phar

mac

ist

61.2

%fo

llow

-up

ever

y2

mo

8m

o(e

ndof

phas

e1)

:96.

9%Ye

s(w

ithin

-gr

oup

for

phas

e1

inte

rven

tion)

RC

Tph

ase:

sam

ein

terv

entio

nfo

rad

ditio

nal6

mo

Bas

elin

e(p

hase

2):6

1.4%

61.1

%N

oM

odel

NR

14m

o(e

ndof

phas

e2)

:95.

5%69

.1%

Yes

Mor

isky

Com

bina

tion

of3

INTs

:4-

item

self-

repo

rtm

easu

reA

dher

ence

Bas

elin

e:N

RN

RN

R(1

985)

231.

10-m

inex

itin

terv

iew

Fam

ilym

embe

rsu

ppor

tat1

8–36

%Ye

s2.

fam

ilym

embe

rsu

ppor

tthr

ough

abo

okle

t24

mo:

52%

3.sm

allt

rain

ing

grou

pM

odel

NR

AC

E=

angi

oten

sin-

conv

ertin

gen

zym

e;A

CT

G=

AID

SC

linic

alTr

ials

Gro

up;A

GA

S=

Ant

iretr

ovira

lGen

eral

Adh

eren

ceS

cale

;BM

I=bo

dym

ass

inde

x;B

P=

bloo

dpr

essu

re;C

OP

D=

chro

nic

obst

ruct

ive

pul-

mon

ary

dise

ase;

HbA

1c=

hem

oglo

bin

A1c

;IN

T=

inte

rven

tion;

ME

MS

=M

edic

atio

nE

vent

Mon

itorin

gS

yste

m;N

A=

nota

pplic

able

;NR

=no

trep

orte

d;R

CT

=ra

ndom

ized

cont

rolle

dtr

ial.

a Unl

ess

othe

rwis

esp

ecifi

ed,a

dher

ence

isde

fined

asa

perc

enta

geof

the

dose

sta

ken

atth

eid

entif

ied

perio

d.To

dete

rmin

esi

gnifi

cant

diffe

renc

esin

adhe

renc

ebe

twee

ngr

oups

,int

erve

ntio

nan

dco

ntro

lgro

upre

sults

wer

eco

mpa

red.

Ifon

ly1

grou

pw

aspr

esen

t,ad

here

nce

was

com

pare

dbe

twee

nba

selin

ean

dfo

llow

-up

perio

ds.

(con

tinue

don

page

974)



Tabl

e2.

Inte

rven

tions

and

Adh

eren

ceM

easu

rem

ents

a(c

ontin

ued)

Sig

nif

ican

tP

rim

ary

Co

ntr

ol

Dif

fere

nce

sR

efer

ence

Inte

rven

tio

nan

dT

heo

reti

calM

od

elA

dh

eren

ceM

easu

rem

ent

Ou

tco

me

Inte

rven

tio

nG

rou

pG

rou

p(p

<0.

05)

Mor

isky

INT

1:pe

erco

unse

ling

Sel

f-re

port

with

varia

tion

of3-

item

Sel

f-ef

ficac

yB

asel

ine:

NR

NR

NR

(200

1)24

INT

2:pa

rent

-par

ticip

antc

ontin

genc

yco

ntra

ctM

oris

kysc

ale

and

mas

tery

INT

1:80

.3%

77.8

%N

oIN

T2:

com

bine

dpe

erco

unse

ling

and

cont

inge

ncy

cont

ract

Cro

nbac

h’s

α=

0.59

INT

2:76

.4%

77.8

%N

oM

odel

NR

Adh

eren

ceba

sed

onth

ose

com

plet

ing

INT

3:84

.8%

77.8

%N

oA

llIN

Ts6

mo

6m

oof

TB

trea

tmen

t

Mor

isky

INT

1:in

divi

dual

ized

pt.c

ouns

elin

gse

ssio

nsS

elf-

repo

rtus

ing

varia

tion

of6-

item

Sys

tolic

and

Bas

elin

e:N

RN

RN

odi

ffere

nces

(200

2)25

INT

2:ap

poin

tmen

ttra

ckin

gM

oris

kysc

ale

dias

tolic

BP

No

brea

kdow

nfo

r6

or12

mo

for

No

brea

kdow

nN

odi

ffere

nces

INT

3:ho

me

visi

tch

ange

any

INT

for

6or

12m

oA

llin

terv

iew

str

ansl

ated

into

Spa

nish

Cro

nbac

h’s

α=

0.68

for

cont

rol

Hea

lthB

elie

fMod

el,T

heor

yof

Pla

nned

Act

ion,

and

Soc

ial

grou

pS

uppo

rtT

heor

y

Mur

phy

Alte

rnat

ing

serie

sof

5gr

oup

and

indi

vidu

alse

ssio

nsov

erS

elf-

repo

rtus

ing

Adu

ltA

CT

GA

dher

ence

Adh

eren

ceB

asel

ine

(mea

n):6

9%62

%N

o(2

002)

267

wk

usin

gbe

havi

oral

chan

gest

rate

gies

,soc

ials

uppo

rt,

Bas

elin

eQ

uest

ionn

aire

7w

k(m

ean)

:87%

87%

No

educ

atio

n3

mo

(mea

n):8

6%83

%N

oM

odel

NR

Oge

degb

e4

mot

ivat

iona

lint

ervi

ewin

gse

ssio

nsev

ery

3m

ofo

r12

mo

Pill

coun

ts,M

edic

atio

nA

dher

ence

Sel

f-A

dher

ence

Not

avai

labl

eN

otav

aila

ble

Not

avai

labl

e(2

007)

27M

odel

NR

effic

acy

scal

e,M

oris

kysc

ale

Pie

tteA

utom

ated

tele

phon

eca

lls(5

–8m

in)

and

nurs

ete

leph

one

Sel

f-re

port

usin

gva

riatio

nof

3-ite

mM

oris

kyM

ean

HbA

1cB

asel

ine:

69/1

24(5

6%)

69/1

24(5

6%)

No

(200

0)28

educ

atio

nov

er12

mo

scal

e,an

ym

edic

atio

nad

here

nce

leve

ls12

mo:

55/1

24(4

4%)

78/1

24(6

3%)

Yes

Spa

nish

-lang

uage

vers

ions

ofca

lls,b

iling

uali

nter

pret

erpr

oble

ms

repo

rted

tran

slat

edm

essa

ges,

inte

rven

tion

nurs

eco

mpe

tent

inS

pani

shM

odel

NR

Pie

tteB

iwee

kly

auto

mat

edte

leph

one

dise

ase

man

agem

enta

ndS

elf-

repo

rt:a

nypr

oble

ms

with

med

icat

ions

Sel

f-ca

re,u

seM

edic

atio

npr

oble

ms

(200

1)29

educ

atio

nca

llsan

dnu

rse

follo

w-u

pca

llsba

sed

onre

port

edof

spec

ialty

base

line:

56%

46%

No

asse

ssm

ent;

Spa

nish

-lang

uage

vers

ion

avai

labl

ese

rvic

es,

12m

o:45

%39

%N

oM

odel

NR

seve

rity

ofdi

abet

es

Rat

hbun

1-to

1.5-

hvi

sita

tsta

rtof

ther

apy

and

30-m

inph

one

Ele

ctro

nic

mon

itorin

gof

1an

tiret

rovi

ral

Adh

eren

ceE

lect

roni

cm

onito

ring

(200

5)30

follo

w-u

pup

to12

wk

drug

(dos

esco

nsum

ed/n

umbe

rof

dose

sba

selin

e:no

tcon

duct

edN

otco

nduc

ted

NA

Mod

elN

Rof

pres

crib

eddo

ses)

;val

idat

edse

lf-re

port

wee

k4:

86%

73%

No

wee

k16

:77%

56%

No

wee

k28

:74%

51%

No

Raw

lings

Inte

ract

ive,

educ

atio

nalp

rogr

amof

4se

ssio

nsco

nduc

ted

ME

MS

caps

HIV

-1R

NA

Bas

elin

e:no

tcon

duct

edN

otco

nduc

ted

NA

(200

3)31

over

4w

kle

vels

24w

k:70

%74

%N

oM

odel

NR

Reh

der

INT

1:dr

ug/d

isea

seco

unse

ling

3tim

esov

er12

wk

Uni

tdos

eco

unto

fdru

gsre

mai

ning

Adh

eren

ce≥9

5%fo

r%

ofpt

s.by

(198

0)32

INT

2:dr

ugco

ntai

ner

only

(with

7-da

ysu

pply

)un

itdo

seco

unt

INT

3:dr

ug/d

isea

seco

unse

ling

and

drug

cont

aine

rba

selin

e:no

tcon

duct

edN

otco

nduc

ted

NA

Mod

elN

RIN

T1:

60%

48%

No

All

INTs

12w

kIN

T2:

88%

48%

Yes

INT

3:90

%48

%Ye

s

Res

nick

60-m

inse

ssio

ns3

times

/wk

for

12w

kS

elf-

repo

rton

5-po

ints

cale

from

0to

4D

ecre

ase

inB

asel

ine:

3.2

(mea

n)N

AN

A(2

009)

54S

ocia

lEco

logi

calM

odel

(4=

adhe

renc

em

osto

fthe

time,

0=

nosy

stol

ican

d14

wk:

3.9

(mea

n)N

o(w

ithin

-ad

here

nce)

dias

tolic

BP

grou

pco

mpa

rison

)



Ric

hN

urse

-dire

cted

,int

ensi

veed

ucat

ion

durin

gho

spita

lizat

ion,

Pill

coun

ts30

days

afte

rdi

scha

rge

(≥80

%S

urvi

vala

t90

Bas

elin

e:N

AN

AN

A(1

995)

33di

etar

yas

sess

men

tby

diet

itian

,con

sulta

tion

with

soci

alof

drug

sta

ken

corr

ectly

)da

ysaf

ter

30da

ys:8

2.5%

ofpt

s.64

.9%

pts.

Yes

serv

ice,

hom

efo

llow

-up

visi

ts,t

elep

hone

cont

acto

ver

hosp

ital

90da

ysdi

scha

rge

Mod

elN

Rw

ithou

tre

adm

issi

on

Rob

bins

Sta

ndar

dize

dte

achi

ngov

er12

mo,

pict

oria

land

verb

alP

illco

unts

;ME

MS

for

min

ority

grou

ps;

Adh

eren

ceP

illco

unts

NA

(200

4)55

inst

ruct

ion,

avai

labl

ein

Spa

nish

and

Eng

lish

stud

y;H

ispa

nic

brea

kdow

npr

ovid

edfo

rba

selin

e:83

.0%

NA

PR

EC

ED

Em

odel

resu

lts3

mo:

83.7

%N

o6

mo:

78.6

%N

o9

mo:

78.5

%N

o12

mo:

85.8

%N

o(w

ithin

-gr

oup

com

paris

on)

Saf

ren

Sin

gle

sess

ion

invo

lvin

gco

gniti

ve-b

ehav

iora

l,pr

oble

mS

elf-

repo

rtA

dher

ence

Que

stio

nnai

reA

dher

ence

Bas

elin

e:74

%84

%N

o(2

001)

34so

lvin

g,an

dm

otiv

atio

nali

nter

view

ing,

1fo

llow

-up

(pts

.doc

umen

tnum

ber

ofpi

llsW

eek

2:95

%90

%N

ote

leph

one

call

1w

kla

ter

pres

crib

edan

dta

ken

each

day)

Wee

k12

:94%

93%

No

Mod

elN

R

Sam

etM

otiv

atio

nali

nter

view

ing

over

3m

o,in

itial

60-m

inap

poin

t-M

EM

Sca

ps(3

0-da

yad

here

nce:

Adh

eren

ce3-

day

adhe

renc

e(2

005)

35m

enta

nd30

-to

45-m

inho

me

visi

t;an

d2

subs

eque

nt15

-di

strib

uted

atba

selin

ean

d12

mo;

only

base

line:

58.0

%65

.0%

No

to30

-min

appo

intm

ents

at1

and

3m

o;m

edic

atio

ntim

erw

eak

asso

ciat

ion

with

self-

repo

rtda

ta;

3m

o:65

.0%

63.0

%N

ode

vice

give

n;al

ldat

aco

llect

ion

inE

nglis

hor

Spa

nish

mos

tdat

ano

tusa

ble)

;sel

f-re

port

13m

o:71

.0%

62.0

%N

oP

rinci

ples

ofM

otiv

atio

nalE

nhan

cem

enta

ndH

ealth

(3-

and

30-d

ayad

here

nce)

30-d

ayad

here

nce

Bel

iefM

odel

base

line:

68.0

%69

.0%

No

3m

o:63

.0%

62.0

%N

o13

mo:

67.0

%64

.0%

No

Sau

nder

sW

ritte

nre

min

ders

topt

s.,p

ts.r

etai

ned

reco

rds

used

asa

Pill

coun

tsat

clin

icvi

sits

Adh

eren

ceB

asel

ine:

notc

ondu

cted

Not

cond

ucte

dN

A(1

991)

36fo

calp

oint

for

coun

selin

gat

clin

icvi

sits

over

6m

oN

ewly

diag

nose

d6

mo:

8/26

3/20

(15%

)N

oM

odel

NR

(31%

)to

ok≥8

0%of

drug

sIn

freq

uent

atte

nder

s6

mo:

25/3

713

/35

(37%

)Ye

s(6

8%)

took

≥80%

ofdr

ugs

Sch

affe

rIN

T1:

30-m

inau

diot

ape

Sel

f-re

port

(pts

.ask

edho

wm

any

dose

sA

dher

ence

Bas

elin

e(2

004)

37IN

T2:

NH

LBIb

ookl

etof

prev

entiv

edr

ugs

mis

sed

inla

stIN

T1:

32%

62%

No

INT

3:au

diot

ape

and

book

let

2w

k);p

harm

acy

reco

rds

INT

2:62

%62

%N

oP

rote

ctio

nM

otiv

atio

nalT

heor

yIN

T3:

41%

62%

No

3m

oIN

T1:

40%

42%

No

INT

2:73

%42

%Ye

sIN

T3:

53%

42%

No

6m

oIN

T1:

48%

40%

No

INT

2:77

%40

%Ye

sIN

T3:

77%

40%

Yes

Sch

war

tz-

One

10-m

inm

otiv

atio

nali

nter

view

with

2ha

ndou

ts,w

ritte

nV

olum

em

easu

reof

antib

iotic

regi

men

;A

dher

ence

Bas

elin

e:N

AN

AN

ALo

okin

land

inS

pani

sh,a

ndpi

ctor

iali

nstr

uctio

nsad

here

nce

usin

g80

%m

issi

ngdr

ugs

10da

ys:6

7.6%

64.5

%N

o(1

989)

38M

otiv

atio

nalT

heor

yto

dete

rmin

epr

opor

tion

ofad

here

ntpt

s.

AC

TG

=A

IDS

Clin

ical

Tria

lsG

roup

;BP

=bl

ood

pres

sure

;HbA

1c=

hem

oglo

bin

A1c

;IN

T=

inte

rven

tion;

ME

MS

=M

edic

atio

nE

vent

Mon

itorin

gS

yste

m;N

A=

nota

pplic

able

;NH

LBI=

Nat

iona

lHea

rt,L

ung

and

Blo

odIn

stitu

te;N

R=

notr

epor

ted;

PR

EC

ED

E=

Pre

disp

osin

g,R

einf

orci

ng,a

ndE

nabl

ing

Cau

ses

onE

duca

tiona

lDia

gnos

esan

dE

valu

atio

n;T

B=

tube

rcul

osis

.a U

nles

sot

herw

ise

spec

ified

,adh

eren

ceis

defin

edas

ape

rcen

tage

ofth

edo

ses

take

nat

the

iden

tifie

dpe

riod.

Tode

term

ine

sign

ifica

ntdi

ffere

nces

inad

here

nce

betw

een

grou

ps,i

nter

vent

ion

and

cont

rolg

roup

resu

ltsw

ere

com

pare

d.If

only

1gr

oup

was

pres

ent,

adhe

renc

ew

asco

mpa

red

betw

een

base

line

and

follo

w-u

ppe

riods

.(c

ontin

ued

onpa

ge97

6)



Tabl

e2.

Inte

rven

tions

and

Adh

eren

ceM

easu

rem

ents

a(c

ontin

ued)

Sig

nif

ican

tP

rim

ary

Co

ntr

ol

Dif

fere

nce

sR

efer

ence

Inte

rven

tio

nan

dT

heo

reti

calM

od

elA

dh

eren

ceM

easu

rem

ent

Ou

tco

me

Inte

rven

tio

nG

rou

pG

rou

p(p

<0.

05)

Sm

ithIn

divi

dual

drug

self-

man

agem

enta

nd3

once

-mon

thly

ME

MS

,Adh

eren

ceC

onfid

ence

Sca

leA

dher

ence

Bas

elin

e:no

tcon

duct

edN

otco

nduc

ted

NA

(200

3)39

follo

w-u

pse

ssio

ns12

wk:

96%

37%

Yes

Ban

dura

Sel

f-E

ffica

cyM

odel

and

Soc

ialC

ogni

tive

The

ory

Sol

omon

Pha

rmac

eutic

alca

repr

ogra

mw

ithsc

hedu

led

visi

tsat

Sel

f-re

port

;4-it

emM

oris

kyS

cale

;pill

Sys

tolic

orB

asel

ine

(199

8)40

base

line

and

1-m

oin

terv

als

for

5vi

sits

upto

6m

oco

unts

durin

gcl

inic

visi

tsdi

asto

licB

PB

Pgr

oup:

61%

nona

dher

ence

60%

No

Mod

elN

Ror

dysp

nea

CO

PD

grou

p:N

RN

RN

oon

exer

tion

6m

oB

Pgr

oup:

63%

nona

dher

ence

23%

Yes

CO

PD

grou

p:N

RN

RN

o

Telle

sB

ehav

iora

lfam

ilyin

terv

entio

nof

wee

kly

sess

ions

for

6m

o,S

elf-

repo

rtus

ing

a5-

poin

trat

ing

ofP

reve

ntin

gB

asel

ine:

NR

NR

No

diffe

renc

es(1

995)

41th

enev

ery

2w

kfo

r3

mo,

then

mon

thly

for

3m

o;bi

cultu

ral

med

icat

ion

adhe

renc

ere

laps

ean

dre

port

edcl

inic

ians

deliv

ered

inte

rven

tion;

inst

ruct

iona

lmat

eria

lsre

duci

ng12

mo:

NR

NR

No

diffe

renc

esav

aila

ble

inS

pani

shps

ycho

ticA

dher

ence

affe

cted

byle

velo

fre

port

edM

odel

NR

exac

erba

tion

accu

ltura

tion:

F=

12.1

2,df

=1.

36,p

=0.

001

van

5-w

kin

stru

ctio

nals

uppo

rtpr

ogra

mw

ith6-

mo

follo

w-u

pw

ithS

elf-

repo

rtus

ing

adhe

renc

equ

estio

nsLe

velo

fhea

lthD

oses

mis

sed

inla

st4

days

1.82

No

Ser

velle

nca

sem

anag

emen

t;co

nduc

ted

inS

pani

shby

bilin

gual

from

the

Adu

ltsA

CT

GA

dher

ence

liter

acy

base

line:

2.38

(200

3)56

prac

titio

ners

Bas

elin

eQ

uest

ionn

aire

Dos

esm

isse

din

last

24h

0.29

No

Mod

elN

Rba

selin

e:0.

56D

oses

mis

sed

inla

st4

days

–62.

16N

ow

k:1.

26D

oses

mis

sed

inla

st24

h–6

0.32

No

wk:

0.29

Vel

ligan

INT

1:M

edic

atio

nad

here

nce

targ

eted

Cog

nitiv

eA

dapt

atio

nU

nann

ounc

edpi

llco

unts

,pha

rmac

yA

dher

ence

Bas

elin

e:N

RN

RN

R(2

008)

42Tr

aini

ng(P

harm

-CA

T)

reco

rds

9m

o56

%Ye

sIN

T2:

Ful

lCA

TIN

T1:

82%

Eac

hin

terv

entio

n30

–45

min

/wk

over

9m

oIN

T2:

84%

Mod

elN

R12

mo

55%

Yes

INT

1:83

%IN

T2:

85%

15m

o58

%Ye

sIN

T1:

80%

INT

2:82

%

Viv

ian

Vis

itto

clin

ical

phar

mac

ist–

man

aged

hype

rten

sion

clin

icS

elf-

repo

rtad

here

nce

surv

ey;p

harm

acy

Cha

nges

inB

PB

asel

ine:

NR

NR

No

(200

2)43

mon

thly

for

6m

o;ph

arm

acis

tpre

scrib

ing

chan

ges

tore

cord

sof

refil

ls(r

efill

ing

drug

sw

ithin

Ref

ills

with

in2

wk–

6m

o:85

%93

%N

ohy

pert

ensi

veth

erap

yan

dm

edic

atio

ned

ucat

ion

give

n2

wk

afte

rsc

hedu

led

refil

ldat

e)S

elf-

repo

rtas

king

iffo

rgot

to48

%N

oM

odel

NR

take

med

icat

ions

≥1tim

e/w

k–6

mo:

68%

Wal

ker

Wee

kly

prog

ram

med

tele

phon

em

essa

ges

onhy

pert

ensi

onH

ome

visi

tsto

cond

uctp

illco

unts

BP

know

ledg

eP

ills

take

n/pi

llspr

escr

ibed

(200

0)44

and

spiri

tual

ityov

er6

wk

base

line:

0.83

0.80

No

Mod

elN

R6

wk:

0.88

1.10

No

Web

bIN

T1:

thre

e1-

hgr

oup

sess

ions

over

3m

oB

ringi

ngdr

ugs

toea

chap

poin

tmen

tA

dher

ence

Bas

elin

e:N

RN

R(1

980)

45IN

T2:

3in

divi

dual

,1-h

coun

selin

gse

ssio

nsfo

r9

wk

(max

imum

of18

)18

mo

Mod

elN

RIN

T1:

4.6

4.8

No

INT

2:5.

04.

8N

o

medication adherence, there was little direct acknowledg-ment of the concepts underlying the national standards onCLAS.8 Furthermore, since many of the CLAS standards aremandated for accredited agencies and organizations receivingUS federal funds, it would be anticipated that the principlesand activities underlying the standards should comprise “usu-al care” given to control groups. Yet, few details were provid-ed about the nature and content of usual care initiatives givento people of CALD backgrounds.

In the majority of studies, there was homogenization ofadherence results for people of CALD and non-CALDbackgrounds. This homogenization can lead to possible di-lution of intervention effectiveness and lack of clarityabout how interventions could be refined and improved infuture work. Demographic characteristics were presentedof various cultural groups, but aside from a few excep-tions,24,55,57 there was a lack of subgroup analysis of adher-ence in participants of different CALD backgrounds. Simi-larly, only a few studies involved recruitment of partici-pants solely from CALD backgrounds.12,16,36,38,41,44,45,51,52,54,56

Another concern was the highly varied terminology usedto describe different population groups. For instance, theterm “Latino” can include a person who has Mexican,Central American, South American, Puerto Rican, orCuban ancestry. Individuals of a Hispanic origin are alsointerpreted in diverse ways, as they have been perceived tobe individuals who come from Spain or Portugal or con-strued to be the same as individuals with a Latino back-ground.63 Such delineations have limitations as they com-prise people from highly diverse cultures. In addition,while the majority of studies tended to focus on people ofHispanic, Latino, or African American backgrounds, littleinterventional work was carried out on indigenous groups,such as Native Americans; people from European, Asianor Middle Eastern, and Pacific countries; and people at ei-ther end of the age spectrum.

Future interventional work should not only target peoplefrom a specific CALD group, but also provide tailoredstrategies that take into account various differences withina particular CALD group, such as attitudes toward diseaseand treatment, educational attainment, religion, family sup-port networks, and socioeconomic background. The pro-cess of developing interventions from patient perspectivesthrough preliminary interviews and surveys can assist inidentifying strategies that would normally not have beenconceptualized if they were developed from health profes-sionals’ perspectives.64

In most studies, measurement of medication adherencerelied heavily on the use of self-reports. Reports from pa-tients, caregivers, and physicians on adherence have beenshown to underestimate the extent of adherence.65 Con-versely, MEMS caps, blood drug concentrations, and phar-macy refill records provide more objective and accurate



Wes

tber

gP

harm

aceu

tical

care

for

med

icat

ion

man

agem

ent,

Pha

rmac

yre

cord

s;%

ofno

n–E

nglis

h-La

ngua

geM

edic

atio

npr

oble

ms

for

NA

NA

(200

5)57

antic

oagu

latio

n,an

dhe

alth

educ

atio

n;fu

ll-tim

ein

terp

rete

rssp

eaki

ngba

ckgr

ound

peop

lew

ithse

rvic

esad

here

nce

inpa

rtic

ipat

ing

clin

ics

med

icat

ion

adhe

renc

epr

oble

ms;

prov

ided

byba

selin

e:31

%N

AN

AM

odel

NR

outc

omes

met

for

med

icat

ion

prob

lem

sph

arm

acie

sO

utco

mes

met

base

line:

58.0

%N

AN

A10

mo:

80.0

%N

R(w

ithin

-gro

upco

mpa

rison

)

Wya

tt11

wee

kly

sess

ions

guid

edby

cogn

itive

beha

vior

alS

elf-

repo

rt:p

ts.a

sked

how

man

yda

ysin

Adh

eren

ceB

asel

ine:

NR

NR

NR

(200

4)46

appr

oach

es,p

sych

o-ed

ucat

ion,

Spa

nish

-spe

akin

gda

tapa

st2

wk

drug

sw

ere

take

non

sche

dule

11w

k:75

.6%

73.3

%N

oco

llect

ors

for

both

grou

psan

dat

right

dose

Trea

tmen

tEng

agem

entM

odel

Yin

1.5-

to3-

min

prog

ram

with

inst

ruct

iona

lshe

ets

and

pict

o-S

elf-

repo

rt:%

ofpt

s.w

hoto

okw

ithin

20%

Red

uctio

nof

Bas

elin

e:N

AN

AN

A(2

008)

47gr

ams;

inst

ruct

ions

inE

nglis

hor

Spa

nish

ofpr

escr

ibed

dose

sdo

sing

3–5

days

:90.

7%62

.0%

Yes

Mod

elN

Rer

rors

AC

TG

=A

IDS

Clin

ical

Tria

lsG

roup

;BP

=bl

ood

pres

sure

;CO

PD

=ch

roni

cob

stru

ctiv

epu

lmon

ary

dise

ase;

INT

=in

terv

entio

n;M

EM

S=

Med

icat

ion

Eve

ntM

onito

ring

Sys

tem

;NA

=no

tapp

licab

le;N

R=

notr

epor

ted.

a Unl

ess

othe

rwis

esp

ecifi

ed,a

dher

ence

isde

fined

asa

perc

enta

geof

the

dose

sta

ken

atth

eid

entif

ied

perio

d.To

dete

rmin

esi

gnifi

cant

diffe

renc

esin

adhe

renc

ebe

twee

ngr

oups

,int

erve

ntio

nan

dco

ntro

lgro

upre

sults

wer

eco

mpa

red.

Ifon

ly1

grou

pw

aspr

esen

t,ad

here

nce

was

com

pare

dbe

twee

nba

selin

ean

dfo

llow

-up

perio

ds.

measures.66 The most commonly used self-report measurewas the Morisky Adherence Scale, which comprises 4items. In the studies reviewed, people were deemed to beadherent if none of the 4 items evoked a “no” response,which suggested no missed doses. With repeated use ofthis scale for testing at various time points, it is possiblethat people may have responded in the same way, thereforeleading to response bias with subsequent loss in sensitivity.The lack of a gold standard in adherence measurementmeans that researchers should be encouraged to use a com-

bination of approaches, such as MEMS, pill counts, pre-scription refills, and validated self-reported measures. Ninestudies involved the use of combinations of different medi-cation adherence measures and 41 studies involved themeasurement of clinical or health outcome variables, suchas blood pressure and number of days of asthma symp-toms. To provide meaningful results to health professionalsand individuals of CALD backgrounds, it is helpful to in-clude clinical or health outcome measurements in futureassessment of adherence.



Figure 3. Meta-analysis of studies using medication adherence as a continuous variable (n = 12).

Figure 2. Meta-analysis of studies using medication adherence as a dichotomous variable (n = 21).



Table 3. Quality Assessment of Studies on Interventions Provided to People of Culturally and Linguistically Diverse Backgrounds

OutcomeSelection Drug Assessor Loss to Reason forCriteria Starters/ Blinded to Follow-Up Loss to Power Mean %

Randomized Clearly Chronic Intervention (%) Follow-Up Calculation QualityReference Design Marked Users/Both Allocation Reported Reported Provided Score

Armour (2004)50 No Yes Both No 21 Yes Yes 64.1

Barbamoto (2009)12 Yes Yes Starters No 41 Yes No 67.6

Berrien (2004)13 Yes, at pt. level No Both No 8 Yes No 67.6

Bonner (2002)14 Yes No Both Yes 16 No No 54.6

Burrelle (1987)15 Yes Yes Both No 11 Yes No 41.5

Canino (2008)16 Yes Yes Chronic users No 1 No No 62.1

Cooper (2009)17 Yes Yes Both Yes 51 Yes Yes 77.4

Dilorio (2003)18 Yes Yes Both Yes 23 Yes No 41.5

Fernandez (2008)51 No Yes Both Yes 14 Yes No 42.1

Gerin (2007)19 Yes Yes Both Yes 38 Yes Yes 77.8

Hirsch (2009)48 Yes Yes Both Yes NR No No 54.6

Jones (2003)20 Yes Yes Chronic users Yes NR No No 49.0

Krier (1999)21 Yes Yes Both No 21 No No 33.7

Lai (2007)52 NA Yes Both No 51 Yes No 48.2

Lam (2008)49 NA Yes Both NA NR No No 57.1

Leal (2008)53 NR No Both No NR No No 52.4

Lee (2006)22 Yes Yes Chronic users Yes 27 Yes No 68.2

Morisky (1985)23 Yes Yes Chronic users NR 28 Yes No 52.6

Morisky (2001)24 Yes No Starters NR 20 No No 44.8

Morisky (2002)25 Yes No Both Yes 47 No No 62.1

Murphy (2002)26 Yes Yes Chronic users Yes 13 Yes No 49.0

Ogedegbe (2007)27 Yes Yes Chronic users Yes 15 Yes Yes 75.9

Piette (2000)28 Yes Yes Both Yes 11 Yes No 67.6

Piette (2001)29 Yes Yes Chronic users Yes 7 Yes No 70.4

Rathbun (2005)30 Yes Yes Starters Yes 23 Yes No 77.2

Rawlings (2003)31 Yes Yes Both Yes 28 Yes No 85.5

Rehder (1980)32 Yes Yes Chronic users NR 28 Yes No 67.0

Resnick (2009)54 NA Yes Chronic users No 9 Yes No 31.0

Rich (1995)33 Yes Yes Chronic users Yes 11 Yes (death only) No 59.3

Robbins (2004)55 NA Yes Both No 12 Yes No 43.5

Safren (2001)34 Yes Yes Both NR 5 No No 35.9

Samet (2005)35 Yes Yes Both Yes 24 No Yes 90.5

Saunders (1991)36 Yes Yes Both Yes 21 No Yes 71.8

Schaffer (2004)37 Yes Yes Chronic users Yes 4 Yes No 71.2

Schwartz-Lookinland (1989)38 Yes Yes Starters NR 6 Yes No 53.8

Smith (2003)39 Yes Yes Both NR 60 No No 62.9

Solomon (1998)40 Yes Yes Chronic users NR NR No No 67.1

Telles (1995)41 Yes Yes Both Yes 10 Yes No 69.6

van Servellen (2003)56 NA Yes Both NR 5 Yes No 53.0

Velligan (2007)42 Yes Yes Chronic users Yes 12 No No 78.3

Vivian (2002)43 Yes Yes Chronic users NR 5 Yes No 72.4

Walker (2000)44 Yes No Both Yes 17 Yes No 47.8

Webb (1980)45 Yes Yes Chronic users No 18 No Yes 47.6

Westberg (2005)57 NA No Both NA NR NR No 30.4

Wyatt (2004)46 Yes Yes Both NR 10 Yes No 50.4

Yin (2008)47 Yes Yes Starters Yes 7 Yes Yes 69.6

NA = not applicable; NR = not reported.

Meta-analyses results showed statistically significantbenefit in improving medication adherence when consider-ing all reviewed studies. However, when subsets of studiesinvolving only people of CALD backgrounds were exam-ined, meta-analyses demonstrated no statistically signifi-cant benefits. The main reason for lack of benefit in thesestudies was the relatively low sample size where, on aver-age, about 48 people participated in the control or interven-tion group. In addition, results of the tests for heterogeneitywere significant, indicating that several factors need to beconsidered when evaluating adherence to medications.Such factors may include the use of community or hospitalsettings as study sites, the types of CALD groups involved,the use of culturally designed materials for interventions,and types of interventions tested.67

LIMITATIONS OF THE REVIEW

Only articles published in English were examined forthis review. Potentially, there may have been studies pub-lished in non-English journals relating to research involv-ing interventions for improving medication adherence inpeople of CALD backgrounds. In addition, research dis-seminated through gray literature, such as conference pa-pers and unpublished reports, was not considered. Only 3studies24,55,57 involving combinations of CALD and non-CALD groups had separate medication adherence resultsfor the distinct groups. Due to the homogenization of med-ication adherence results for CALD and non-CALDgroups, it was not possible to fully determine the impact ofinterventions. Nevertheless, meta-analyses results on 7studies in which 100% of the participants were from aCALD background indicated that interventions did notproduce a significant impact on medication adherence.

Recommendations

Generally, the reviewed studies had interventions thatsometimes lacked articulation or reproducibility, missingcontrols, insufficient explanation of usual care initiatives, in-adequate focus of minority populations in recruitment andanalysis, missing power calculations, and inappropriate ormissing statistical analyses. In developing well-designed in-tervention studies, greater attention needs to be given to ex-amining the needs of specific CALD population groups. Apredominant focus on bilingual peer-support people to deliv-er the intervention or the use of translated materials is insuffi-cient to address the complex needs of CALD people. Instead,future researchers should consider gathering data from pa-tient perspectives that can be used in interventions to take intoaccount the enormous diversity that exists within any particu-lar CALD group, such as values, beliefs, communicationstyle, self-esteem, lifestyle activities, social support systems,language, religion, and socioeconomic status. It is therefore

important to minimize generalizations even within oneCALD group. Well-developed interventions that are rigor-ously tested are more likely to succeed in improving medica-tion adherence.

Elizabeth Manias MPharm RN PhD, Professor, Melbourne Schoolof Health Sciences, Faculty of Medicine Dentistry and Health Sci-ences, The University of Melbourne, Melbourne, AustraliaAllison Williams RN PhD, Senior Research Fellow, MelbourneSchool of Health Sciences, Faculty of Medicine Dentistry and HealthSciences, The University of MelbourneReprints: Professor Manias, Melbourne School of Health Sciences,Faculty of Medicine Dentistry and Health Sciences, The University ofMelbourne, Level 5, 234 Queensberry St., Carlton, Victoria 3053,Australia, fax 61 3 9317 4375, [email protected]

Conflict of interest: Authors reported none

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Adherencia a Medicamentos en Personas con Trasfondos Culturales yLingüísticos Diversos: una Revisión Sistemática y un Meta-Análisis

E Manias y A Williams


EXTRACTO

TRASFONDO: La adherencia a los medicamentos es de particularimportancia para personas de trasfondos culturales y lingüísticosdiversos (TCLD) debido a la dificultad con el lenguaje, falta de apoyosocial y organizacional, falta de acceso a los recursos de cuidado de lasalud y desencaje con el sistema de cuidado de salud.

OBJETIVO: Evaluar el impacto de intervenciones para mejorar laadherencia a medicamentos en personas con TCLD a través de unarevisión sistemática y meta-análisis.

MÉTODO: Se realizfi una búsqueda utilizando las siguientes fuentes deinformación: The Cochrane Database of Systematic Reviews,Cumulative Index to Nursing & Allied Health Literature, EMBASE,Journals@OVID, PsychInfo, PubMed, Science Direct, Scopus, y Web ofScience. La búsqueda cubrió desde enero 1978 hasta octubre 2009.

RESULTADOS: Cuarenta y seis artículos revisados se evaluaron comorelevantes, los cuales incluyeron 36 estudios aleatorios y controlados, 2estudios observacionales de cohorte, y 8 estudios cuasi experimentales.El método más común para evaluar adherencia a medicamentos fuemétodos de auto-informe, tales como la escala Morisky y susmodificaciones. Algunos estudios utilizaron combinaciones de medidasde adherencia, y la adherencia incluyendo sistemas de monitoreo deeventos de medicación (SMEM) se utilizfi en solamente 6 estudios.Individuos de TCLD fueron reclutados conjuntamente con personas contrasfondos no-culturalmente o lingüísticamente diversos y los análisissubsiguientes tendieron a cubrir toda la muestra. Veinte estudiosdemostraron mejoría estadísticamente significativa en la adherencia amedicamentos, 15 de los cuales fueron estudios aleatorios y controlados.Seis de las intervenciones exitosas incluyeron la entrega por una personabilingüe o el uso de material traducido, y 4 incluyeron el uso de unmodelo conceptual. Los meta-análisis demostraron mejoría moderada enla adherencia a medicamentos.

CONCLUSIONES: Se han realizado relativamente pocos estudios de altacalidad sobre intervenciones para aumentar la adherencia amedicamentos en personas de TCLD. Se necesita que se dé másatención a examinar las necesidades específicas de grupos poblacionalesde TCLD. Los futuros investigadores deben considerar evaluarrigurosamente las intervenciones que toman en cuenta la enormediversidad y diferencias que existen en cualquier grupo particular deTCLD.

Traducido por Giselle Rivera Miranda

Adhésion aux Médicaments chez une Population avec DiversitéCulturelle et Linguistique: Une Revue Systématique et une Méta-Analyse.

E Manias et A Williams


RÉSUMÉ

OBJECTIF: Évaluer l’impact des interventions pour améliorer l’adhésionaux médicaments chez une population avec diversité culturelle etlinguistique via une revue systématique et une méta-analyse.

MÉTHODES: Une recherche a été effectuée dans les banques de donnéessuivantes: Cochrane Database of Systematic Reviews, Cumulative Indexto Nursing & Allied Health Literature, EMBASE, Journals@Ovid,PsychInfo, PubMed, Science Direct, Scopus, et Web of Science. Lesbanques de données ont été explorées de janvier 1978 à octobre 2009.

RÉSULTATS: Un nombre de 46 articles de revue ont été évalué commeétant pertinent; ceci incluait 36 articles randomisés, 2 étudesobservationnelles de cohorte et 8 études avec devis quasiexpérimentales. La méthode la plus fréquemment utilisée pour évaluerl’adhésion aux médicaments était un questionnaire d’auto-estimation soitl’échelle Morisky modifiée. Peu d’études ont utilisé d’autres méthodespour évaluer l’adhésion au traitement et un système de surveillance desévénements de médication a été utilisé dans 6 études seulement. Lespersonnes avec diversité culturelle et linguistique ont été recrutées avecles personnes sans diversité culturelle et linguistique et les analysespostérieures avaient tendance à inclure l’échantillon au complet. Vingtétudes ont démontré une amélioration statistiquement différente dansl’adhésion aux médicaments dont 15 étant des etudes cliniquesaléatoires. Six des interventions les plus réussies ont impliqué laprésence d’une personne bilingue ou l’utilisation des documents traduitset dans 4 des interventions l’utilisation d’un modèle conceptuel. Lesméta-analyses ont démontré des améliorations modestes dans l’adhésionaux médicaments.

CONCLUSIONS: Il existe peu d’études de bonne qualité pour évaluerl’adhésion aux médicaments chez une population avec diversitéculturelle et linguistique. Une attention particulière doit être portée auxpopulations avec diversité culturelle et linguistique. Les études à venirdoivent valider des interventions qui prennent en considération lesdifférences qui existent dans les différents groupes avec diversitéculturelle et linguistique.

Traduit par Louise Mallet

Medication Adherence in People of Culturally and Linguistically Diverse Backgrounds: A Meta-Analysis

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