REVIEW

Interventions combining motivational interviewing and cognitive behaviour to promote medication adherence: a literature review Sandra L. Spoelstra, Monica Schueller, Melissa Hilton and Kimberly Ridenour

Aims and objectives. This article presents an integrative review of the evidence for combined motivational interviewing and cognitive behavioural interventions that promote medication adherence. We undertook this review to establish a scientific foundation for development of interventions to promote medication adherence and to guide clinical practice. Background. The World Health Organization has designated medication adherence as a global problem. Motivational interviewing and cognitive behaviour interventions have been found to individually promote medication adherence. However, there is a gap in the literature on the effect of combined motivational interviewing and cognitive behavioural approaches to promote medication adherence. Design. Integrative review. Methods. COCHRANE, PubMed and CINAHL were searched to access relevant studies between 2004–2014. Inclusion criteria were interventions combining motivational interviewing and cognitive behavioural therapy with medication adherence as the outcome. Articles were assessed for measures of adherence and methodological rigour. Analysis was performed using an integrative review process. Results. Six articles met the inclusion criteria. A randomised controlled trial reported pretreatment missed doses of 558 and post-treatment of 092 and trended towards significance. Four cohort studies had effect sizes of 019–035 (p < 005). A case study had a pretreatment adherence rate of 25% and post-treatment 77% (p < 001). Conclusions. Although there were a limited number of studies on combined motivational interviewing and cognitive behavioural interventions, five out of six were effective at improving medication adherence. Future studies with large rigorous randomised trials are needed. Relevance to clinical practice. This review provides clinicians with the state of the science in relation to combined motivational interviewing and cognitive behavioural therapy interventions that promote medication adherence. A summary of intervention components and talking points are provided to aid nurses in informing decision-making and translating evidence into practice.

What does this paper contribute to the wider global clinical community?

• Reporting on how motivational



interviewing and cognitive behavioural therapy promote medication adherence rates. Providing talking points for nurses regarding interactions with patients using motivational interviewing and cognitive behavioural therapy to promote medication adherence.

Key words: cognitive behavioural therapy, integrative review, intervention, medication adherence, motivational interviewing Accepted for publication: 12 October 2014 Authors: Sandra L Spoelstra, PhD, RN, Assistant Professor, Michigan State University College of Nursing, East Lansing, MI; Monica Schueller, BA, Project Manager, Michigan State University College of Nursing, East Lansing, MI; Melissa Hilton, BSN, RN, Graduate Nursing Student, Research Assistant, Michigan State University College of Nursing, East Lansing, MI; Kimberly Ridenour, Undergraduate Nur-

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1163–1173, doi: 10.1111/jocn.12738

sing Student, Nurse Scholar, Research Assistant, Michigan State University College of Nursing, East Lansing, MI, USA Correspondence: Sandra Spoelstra, Assistant Professor, Michigan State University College of Nursing, 1355 Bogue Street, Room C342, East Lansing, MI 48824, USA. Telephone: +1 517-353-8681. E-mail: [email protected]

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Introduction The World Health Organization (2003) has acknowledged that medication adherence is a global problem, particularly for long-term therapies. Healthcare providers are challenged to finds ways to promote medication adherence to assure patients achieve the best possible health outcome (Haynes et al. 2008). A review of 50 years of research across diseases found a medication adherence rate of 745% (DiMatteo 2004). Poor medication adherence has been shown to have a significant impact on morbidity, mortality and healthcare costs (Viswanathan et al. 2012a). Most researchers and clinicians have concluded that medication adherence is a complex phenomenon influenced by physical, psychological, cognitive, social and economic factors (Lewis 2012). Identifying effective interventions to improve medication adherence may ultimately result in significant improvement in health outcomes and costs (Haynes et al. 2008, Viswanathan et al. 2012b).

CBT is based on the belief that negative thoughts (e.g. not believing the medication will help) can block the abilities to take action and learn new behaviours (e.g. refill a prescription or taking a medication at the prescribed time). Meta-analysis of 33 trials on interventions designed to improve medication adherence found an Effect Size (ES) of 033 for brief CBT (Conn et al. 2009). Many experts believe CBT is an essential component of medication adherence interventions; however, it is often insufficient (Haynes et al. 2008). Others have reported that a major barrier to adherence involves motivation (Possidente et al. 2005). Use of a motivational approach like MI, in addition to CBT, may be needed to promote adherence in some challenging clinical conditions, such as in human immunodeficiency virus (HIV) patients treated with antiretroviral therapy (ART) or in cancer patients prescribed oral anti-cancer agents, where medication adherence is needed for life sustaining treatment.

MI and its use for promoting adherence Medication adherence and nonadherence

Determinants of adherence are known to be multifactorial with reviews of the literature suggesting there is no single or simple solution, with most effective interventions targeting multiple factors (WHO 2003). A review of 64 medication adherence interventions found motivational interviewing (MI), cognitive behavioural therapy (CBT), and patient education to be somewhat effective (Ruppar et al. 2008). Yet, it remains unclear which interventions are best to promote medication adherence in clinical practice (Ruppar et al. 2008, Conn et al. 2009). In this paper, we focus on CBT and MI.

Motivational interviewing works on facilitating and engaging intrinsic motivation within patients to change behaviour (Miller & Rollnick 2012). MI is a goal-oriented, focused, and patient-centred approach to elicit behaviour change by helping patients explore and resolve ambivalence. Patients may have thoughts about behaviour change but have not taken action steps. Thus, the focus is on increasing motivation to achieve action (i.e. a desired behaviour such as medication adherence). A large body of literature indicates that MI is effective for either stopping harmful behaviours or adopting healthy behaviours (Rubak et al. 2005, Gance-Cleveland 2007). Studies using MI to promote medication adherence in various conditions have demonstrated an ES ranging from 022–067. This includes conditions such as asthma, HIV, and epilepsy (DiIorio et al. 2008, 2009, Riekert et al. 2011). In certain conditions like HIV or cancer, 100% medication adherence may be necessary to assure treatment effectiveness, thus a more robust intervention may be needed (Gebbia et al. 2012, Bozic et al. 2013) .

CBT and its use for promoting medication adherence

Combining MI and cognitive CBT

Cognitive behavioural therapy is a short-term, goal-oriented, psychotherapeutic approach which is founded on the idea that thoughts cause feelings and, consequently, behaviour (Lambert et al. 2004). CBT combines psychological and behavioural therapy and includes assessment, reconceptualisation and skill acquisition and application. The psychological component emphasises the significance of the meaning placed on things and how patterns of thinking are established. The behavioural component examines problems, behaviours, and thoughts.

Several studies have combined MI and CBT interventions. The majority of MI–CBT studies focused on behavioural issues such as alcoholism or gambling, and are reported elsewhere (Greenwald 2002, Hides et al. 2011). There are a few studies of MI–CBT in challenging clinical conditions. A randomised controlled trial (RCT) in Type-1 diabetes patients found MI–CBT promoted treatment adherence as glycated haemoglobin A1c was 045% lower (Confidence Interval [CI] 015–079; p = 0008) at 12 months compared to usual

Medication adherence is defined as the extent to which patients follow the prescribed treatment (Haynes et al. 2008). Nonadherence, not following the prescribed treatment, is often examined, as it can lead to poor health outcomes (Haynes et al. 2008). These definitions guided our review.

Interventions to promote medication adherence

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Review

care (Ismail et al. 2010). A second RCT in patients with moderate to severe traumatic brain injury found that those who received MI–CBT experienced greater reduction in stress, anxiety and unproductive coping compared to those who received only CBT or usual care (p < 001) (Hsieh et al. 2012). A cohort study on weight loss in patients after bariatric surgery found MI–CBT promoted treatment adherence, resulting in a mean weight loss of four pounds (range 0–6) over 18 months (Stewart et al. 2010). These three MI–CBT studies (total n = 385) improved health outcomes in challenging clinical conditions. In view of these findings, we examined the literature to determine if MI–CBT interventions improved medication adherence rates.

Aims To date, evidence supports that MI and CBT interventions individually improved medication adherence, and combined MI–CBT interventions improved some behavioural and physical health outcomes in alcoholism, gambling, obesity, diabetes and traumatic brain injury. The aim of this review was to examine combined MI–CBT interventions that promoted medication adherence. Objectives were: (1) to report and summarise evidence of combined MI–CBT interventions to promote medication adherence, and (2) to report intervention components and talking points which helped improve adherence for patients prescribed medications for translation into clinical practice.

Methods Study design: Integrative review A review method informed by Whittenmore and Knafl (2005) was used for this article. Two steps were used to identify articles. First, electronic databases were searched for pertinent articles published over the past 10 years. Second, the reference lists of identified articles were searched for relevant studies.

Inclusion and exclusion criteria To address the aims, articles reporting on the evaluation of interventions that met the predetermined inclusion criteria were chosen for this review. Inclusion criteria consisted of: (1) English language, peer reviewed articles published from 2004– 2014; and (2) articles combining MI–CBT in an intervention to improve medication adherence rates. Exclusion criteria consisted of: (1) articles that did not include interventions; and (2) articles that did not report on the influence of the intervention on medication adherence rates. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1163–1173

MI and CBT to promote medication adherence

Search strategies Using these review steps, we examined the literature for articles that combined MI–CBT interventions to promote medication adherence. First, searches in COCHRANE, PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were conducted to locate peer reviewed articles published between 2004–2014. Keywords were ‘motivational interviewing/motivational interview’, ‘cognitive behavioral therapy/cognitive behavioral/cognitive behavior’, ‘intervention/ randomized controlled trial/trial/study’ and ‘medication adherence’. Second, the references for those articles were reviewed for other relevant articles.

Data extraction and analysis Data were extracted on study characteristics and intervention components, as well as results related to the effects of the MI– CBT intervention on medication adherence rates. Data extractions were completed by four reviewers. Two reviewers searched to locate articles that met the inclusion criteria and independently read the articles and documented pertinent information. The other two reviewers read the articles and confirmed the accuracy of the material. This iterative process continued until consensus was reached on the articles that met the inclusion.

Literature search As shown in the Fig. 1, we found 1886 articles on MI and 28,429 on CBT in the English language within the past 10 years. When we combined the terms ‘MI–CBT’, this narrowed to 206 articles. We reviewed the articles for use of an intervention and found 100. These 100 articles were examined using the inclusion criteria until agreement was reached on articles to include in this review. Six articles were identified that met the inclusion criteria, an MI– CBT intervention that promoted medication adherence and reported on the effect of the intervention (i.e. rate of adherence).

Results The six studies found to promote medication adherence using a MI–CBT intervention that reported rates of adherence included one RCT, four cohort studies and one case study. Table 1 describes study characteristics and Table 2 provides information on intervention components. The following describes the six studies.

Critical appraisal of selected studies Due to the diverse representation of our articles, the six studies were critically appraised using the Whittenmore and Knafl

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Articles in English in past 10 years on motivational interviewing N = 1,886

Articles in English in past 10 years on cognitive behavioral therapy N = 28,429

Articles identified combining motivational interviewing and cognitive behavioral therapy N = 206 Articles excluded: Not an intervention N = 106 Articles identified and screened combining motivational interviewing and cognitive behavioral therapy in an intervention N = 100

Articles used in review N=6

Articles excluded: Intervention did not influence outcome of interest: medication adherence N = 94

Figure 1 Flow chart of articles found on combined motivational interviewing and cognitive behavioural therapy for this review.

(2005) method. We rated these articles using the two-point scale, high or low, on two-elements, methodological rigour and data relevance. The RCT rated high for both rigour and relevance, as there was a control group and the topic fit our inclusion criteria (Parsons et al. 2005). The four cohort studies rated low for rigour, as the comparison groups were to national reference data rather than to a control group, and rated high for relevance, matching our inclusion criteria (Cook et al. 2007, 2008, 2009, 2010). The case study was well designed, as it used an electronic device as a medication measure, yet rated low for rigour as there was no control group, and rated high for relevance as the topic fit our inclusion criteria (Hilliard et al. 2011). Using this method to critically appraise the level of evidence on combined MI–CBT interventions to improve medication adherence rates demonstrated the need for further intensive research. Nonetheless, we summarised articles that were available.

Three methods of measuring medication adherence were used among the six studies: self-report (n = 5), pharmacy fill records (n = 4) and an electronic pill bottle (n = 1) (see Table 1). The RCT measured adherence by self-report (Parsons et al. 2005). In the cohort studies, medication adherence rates were measured by self-report and pharmacy fill records (Cook et al. 2007, 2008, 2009, 2010). In the case study, an electronic pill bottle was used to measure adherence (Hilliard et al. 2011).

Study characteristics

Intervention characteristics and components

The six studies included in this review were published between 2005–2011. The majority of the interventions were implemented in patient homes.

The RCT (n = 15, mean age 44 [SD 77], 94% male) was conducted on adherence to ART in patients with HIV. Interveners were master’s prepared therapists with a degree in psychology and had additional training in MI and CBT (Parsons et al. 2005). The intervention consisted of individual face-to-face sessions held once a week for one hour, over eight weeks, with follow-up via phone for three months. Seventy-three percentage of the patients completed all eight weekly sessions, and there was an 80% retention rate for the three month phone

Participant characteristics The sample size among these six studies ranged from 1–402 patients, with an overall total of 845 participants. Age ranged from 17–94 years old, with an overall mean of 479 years

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(standard deviation [SD] 12). Collectively, 753% (range 40– 100%) were female. Race was not consistently reported. Interventions targeted different clinical populations, including patients with HIV, osteoarthritis, ulcerative colitis, Fanconi anaemia and psychiatric disorders.

Measures of medication adherence

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1163–1173

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1163–1173 Cohort trial Cohort trial

Cohort trial Case study

Randomised controlled trial pilot

n = 51 n = 98

n = 278 n=1

n = 15

Psychiatric

HIV

Parsons et al. (2005)

Cook et al. (2010) Hilliard et al. (2011)

Ulcerative colitis

Fanconi anaemia

HIV Antiretroviral therapy

Cook et al. (2008) Cook et al. (2009)

Cohort trial

n = 402

Osteoarthritis

Cook et al. (2007)

Type of study

Medication

Author (year)

Sample size (n)

Face-to face and phone

Face-to-face

Phone

Phone

Phone

Phone

Mode of delivery

Therapist

Therapist

RN

RN

Registered nurses (RN)

Type of Intervener

Eight sessions face-to-face; phone not reported

41 call at-risk; 21-calls low-risk 35 sessions

735 calls at-risk; one-call low-risk Four calls at-risk; one-call low- risk

Five calls at-risk; three-calls low- risk

Number of contacts (mean)

One hour

One hour

11 minutes

75 minutes

11 minutes

15 minutes

Duration of contact (mean)

Six months

Six months

Four months

Six months

44 months

Four months

Duration of intervention (mean)

Self-report adherence

Pharmacy fill records & self-report Electronic monitoring

Pharmacy fill records & self-report Pharmacy fill records & self-report

Pharmacy fill records & self-report

Outcome Measures

Effect size (ES) of intervention was 019 over the 2 time periods (three & six months) ES of intervention in six months was 022 ES 025 for receipt of script; and 025 for 95% adherence ES of intervention was 035 Adherence: pre-53% post-77%; 82% at final p < 001 Trend towards better adherence but not statistically significant in small sample size

Major findings in study

Table 1 Articles in review on motivational interviewing (MI) and cognitive behavioural therapy (CBT) combined on medication adherence: author, year, type of medication, sample, type of study, mode of delivery, type of intervener, number of contacts, duration of contact, outcome measures and major findings in study

Review MI and CBT to promote medication adherence

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SL Spoelstra et al. Table 2 Articles in review on motivational interviewing (MI) and cognitive behavioural therapy (CBT) combined on medication adherence: author, year, components of intervention Author (year)

Components of interventions

Cook et al. (2007)

Assessment of adherence risk factors to determine at-risk or low-risk for nonadherence. Follow-up by phone whether or not had started medication and if currently adherent. If the medication not started or if it was stopped but patient wanted treatment, focused on relationship building and answering questions to build motivation for adherence. If started medication but was having difficulty remaining adherent or had questions about the medication, focused on problem-solving and support to address patients concerns. The goal was to resolve barriers to medication adherence by increasing self-efficacy and motivation. Practiced medication-taking behaviours and skills on the phone to self-manage Assessment of adherence risk factors to determine at-risk or low-risk for nonadherence. Each patient worked with the same registered nurses (RN). Cued content of phone call on the individual’s barriers to adherence and readiness for change. Followed-up the phone call by mailing written materials. A written progress note was sent to the health plan case manager after each call. Adverse events occurrences were reported to primary care providers Assessment of adherence risk factors to determine at-risk or low-risk for nonadherence. Assessment of concerns and barriers to adherence on each phone call. Each patient worked with the same RN. The phone call was based on the individual’s readiness to change. The goal was to motivate patient adherence to antiretroviral therapy medication. Emphasis was on patient concerns, to meet their individual needs. Educational information was provided in response to the patient requests and needs. Assessment of adherence risk factors to determine at-risk or low-risk for nonadherence. Assessment of adherence. A manual with predetermined phone call scripts was used. The content of the phone call was based on patient concerns, and readiness to change. Addressed cognitive and emotional reactions during phone calls. Questions to reduce ambivalence about treatment were addressed as they occurred. Addressed negative beliefs about treatment were addressed as they occurred. Addressed coping with adverse events A treatment plan was devised integrating family involvement in the plan of care. Addressed discrepancies between values and behaviours to medication adherence. Highlighted barriers and promoters of medication adherence. Addressed mood, anxiety and barriers to adherence. Goal setting and problem-solving occurred in each interaction Content provided: coping, managing thoughts, reaching out for social support, managing negative moods, communicating with health care providers, making time for oneself, participating in pleasant activities and managing side effects (used as needed). A written self-monitoring card to track medication adherence was provided to the patient. Phone calls monitored adherence and attainment of goals. Focused on acquired skills and future goals in last session

Cook et al. (2008)

Cook et al. (2009)

Cook et al. (2010)

Hilliard et al. (2011)

Parsons et al. (2005)

follow-up. The initial face-to-face sessions were conducted shortly after the baseline interview. Sessions one and two focused on exploring ambivalence, building confidence for medication-taking behaviours, and setting realistic objectives. The third session concentrated on triggers that led to missing medication doses. Sessions 4 through 7 provided content to meet individual needs based on the identified triggers from session 3. The final session focused on setting goals and developing skills needed to promote medication adherence in the future. Patients were provided cards to track their medication adherence. The three month follow-up phone calls monitored adherence and goal attainment.

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The four cohort studies addressed the cognitive and emotional factors related to medication adherence (Cook et al. 2007, 2008, 2009, 2010). Using CBT, they focused on negative beliefs about treatment, and using MI, they minimised treatment ambivalence (Miller & Rollnick 2002). The intervention used the Prochaska et al. (1994) model of readiness to change and assessed ability to adopt medication-taking behaviours. Assessment of risk of medication nonadherence was conducted on the first contact with patients in each of these four studies (Cook 2006). The assessment included previous medication adherence, social support, and complexity of the treatment regimen and identified patients at-risk or low-risk for nonadherence using an © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1163–1173

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algorithm (Cook 2006). Doses of the interventions varied based on at-risk or low-risk in each of the four cohort studies. The first cohort study examined osteoarthritis patients (n = 402, mean age 669 [SD 125], 94% female) prescribed risedronate sodium (Cook et al. 2007). Ninety-five percentage (n = 382) of the patients had not started their medication prior to enrolment, while the other 5% (n = 20) were, on average, 133 (SD = 114) days into treatment. Four registered nurses (RNs) conducted the intervention by phone. On the first contact, 647% (n = 260) were identified as at-risk for nonadherence while 353% (n = 142) were considered low-risk, using the algorithm-based risk assessment (Cook 2006). The at-risk for nonadherence patients received a median of five-phone contacts (interquartile range 3–8). The low-risk for nonadherence patients received a median of three-phone contacts (interquartile range 2–8). Patients were followed for a mean of 41 months (range 0–14). On the first contact, the RN asked the patient whether or not they had started treatment and if they were adherent to their medication. For those patients who had not started taking their medication or who had stopped their medication but had a desire to restart, the RN focused on responding to questions to motivate the patient to start or restart treatment. For those patients who had started treatment but were having trouble with adherence or had medicationrelated questions, the RN focused on addressing patient concerns and problem-solving. The overall goal of the intervention was to increase self-efficacy and motivation to promote medication adherence and to resolve barriers to adherence. During the phone calls, the RNs encouraged patients to practice skills to manage medication-taking behaviours, such as using pillboxes or creating a routine. Average duration of the phone calls among both groups were 153 minutes. The second cohort study (n = 278, mean age 49 [SD 177], 66% female) examined mesalamine use on patients with ulcerative colitis (Cook et al. 2010). The MI–CBT intervention was conducted by RNs via phone, with the same nurse contacting the same patient over the course of the study. The RNs prior clinical experience included caring for patients who had mental health issues. Seventy-three percentage (n = 203) of the patients were at-risk for medication nonadherence using the algorithmbased assessment (Cook 2006). The intervention was initiated within one day of the medication start date and patients were followed for a mean of six months (SD = 14). Predetermined semi-structured scripts were used for all RN phone calls. This intervention was based on patient concerns about readiness to change, addressing both cognitive and emotional reactions rather than only providing information. For example, MI was used to lessen uncertainty surrounding treatment and CBT was used to respond to negative beliefs regarding treatment or to deal with adverse events. On average, patients received 42 calls (SD = 26) with a mean call length of 135 minutes (SD = 44).

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1163–1173

MI and CBT to promote medication adherence

The third cohort study in psychiatric disorders (n = 51, mean age 33 [SD 82], 84% female) was conducted on patients prescribed the antipsychotics aripiprazole, ziprasidone, risperidone, quetiapine or olanzapine (Cook et al. 2008). The intervention was conducted by three RNs via phone, with each nurse contacting the same patient over the course of the study. Participants were members of a managed care plan and were prescribed their medication within the past 30 days. Ninety percentage (n = 46) of the participants were identified to be at-risk for nonadherence, using the algorithm-based assessment (Cook 2006). Patients at-risk for nonadherence received an average of 35 phone calls over an average of 44 months. Participants at low-risk for nonadherence were provided a toll-free phone number on the first contact when the risk assessment was completed and received one additional call at six months. On each call, the RN intervened by discussing the willingness of the participant to change and on adherence barriers. The average duration of the phone calls was 11 minutes. The final cohort study (n = 98, mean age 44 [SD = 93], 67% male) was conducted on HIV patients on ART treatment (Cook et al. 2009). RNs (n = 10) intervened via phone, with each study participant assigned to the same nurse throughout the study. Ninety-two percentage (n = 90) of the patients were new to ART treatment. Patients identified at-risk for nonadherence to ART medication using the algorithm-based assessment, received, on average, 30 calls (range 1–14) over the course of the study (Cook 2006). Those at low-risk for nonadherence to ART medication received one call at six months. The goal was to motivate patients to adhere to their ART treatment. When the RNs were trained, emphasis was placed on focusing on the concerns of the patient rather than providing volumes of information. Consequently, the information provided was not standardised, but in response to patient request and need. Average length of phone calls was five minutes (SD = 117). The case study (n = 1, age 17, female) examined a patient with Fanconi anaemia who was prescribed eight medications (albuterol, cyproheptadine, fexofenadine, fluticasone, levothyroxine, montelukast, ompepazole and vitamin supplements) (Hilliard et al. 2011). The intervention was conducted by a trained therapist and included 35 weekly face-to-face MI–CBT sessions, each lasing one hour. The patient was followed for 158 months. An electronic pill bottle was provided to measure adherence. The caregivers, a parent and sister, were also involved in the care throughout the intervention.

Effectiveness of the Interventions on Medication Adherence At baseline, the RCT on adherence to ART treatment for HIV patients reported a 466% (n = 7) rate of nonadherence in the past two weeks, 33% (n = 5) nonadherence in the past two

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days and 133% (n = 2) nonadherence in the last 24 hours (Parsons et al. 2005). During follow-up at three months, 33% (n = 4) reported nonadherence in the past two weeks, 88% (n = 1) nonadherence in the past two days and none nonadherence in the past 24 hours. Thus, pretreatment nonadherence rates were 558 (over a two week period) compared to 092 post-treatment nonadherence rates, trending towards significance. In the cohort studies, intervention ES were established (Cook et al. 2007, 2008, 2009, 2010). These ES were established by comparing the adherence rate in the sample to national reference data. In the osteoarthritis study, adherence rates were higher at three months (v2 = 732; p = 0007) and at six months (v2 = 675; p = 0009) when compared to the national reference data (Cook et al. 2007). The ES of the intervention were 019 at both three and six months. In this study, adherence rates were also compared between the intervention group and those who were referred to the study but chose not to partici-

pate. The intervention group had a medication adherence rate of 69%, and the referred to the study but not participating patient adherence rates were 63%, trending towards significance (v2 = 2034; p = 006) with an ES of 033 at six months. In the ulcerative colitis study, four patients had not started treatment at baseline and three out of those 4 (75%) agreed to initiate treatment after receiving the intervention (Cook et al. 2010). Nineteen patients (7%) stopped their medication prior to the intervention and 10 of those 19 (53%) agreed to resume after the intervention was conducted. Overall, adherence rates at six months were greater than the population norm (v2 = 222; p < 0001) with an intervention ES of 035. In the antipsychotic study, pharmacy fill rates in the intervention group were 59% (n = 29 of 51) at three months and 48% at six months, notably greater than the population base (v2 = 801; p = 0004) (Cook et al. 2008). Regarding those with nonadherence, 98% (n = 5) failed to fill the initial pre-

Table 3 Examples of talking point using motivational interviewing (MI) and cognitive behavioural therapy (CBT) to promote medication adherence: topic and example talking point Topic

Example talking points to promote medication adherence

Introduction

I am going to discuss your care at home regarding your treatment. You and your doctor have decided that taking this medication is the right choice for you. It’s important to understand how to go about managing your medication at home. Together, we will decide what things will work best for you and you will decide what your goals are. We will work with the doctor, as a team, to help make managing at home easier Taking a new medication is important and requires a change to your usual routine, how ready are you to make these changes? It is important for me to get a better understanding how ready you are for change so I am going to ask you a few questions. Is it all right if we proceed? How ready are you for change? On a scale of 0–10, with 0 being not ready, 5 being considering change, and 10 being ready for change. How ready are you for change? How important is this change to you? How confident are you that you can make this change? (For those with less than a 10.) Why did you choose a 7 (insert number), not a 10? What would have to happen to make it a 10? First, we are going to discuss your medication to identify what you know about your medication; and if you may need additional information. Have you ever forgotten to take your pill in the past seven days? What would you do if you forgot to take your medication? What happens when you take your medication less often than prescribed? Would you skip or stop taking your medication because you did not think it was working? Would you skip or stop taking your medication because it made you feel bad? Have you ever taken more pills that you were prescribed in the past seven days? What happens when you take your medication more often than prescribed? Did you forget to take your medication and double up a dose? Next we are going to discuss actions you can take to take your medication properly at home. What ideas do you have to help you remember to take your medication? Do you take your medication at the same time you usually do something else, like eat breakfast, brush your teeth, or weigh yourself? How do you know if you are reaching your health goals? What goals to you have for the next week?

Assessing readiness for change

Adherence

Goal setting

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Interventions combining motivational interviewing and cognitive behaviour to promote medication adherence: a literature review Sandra L. Spoelstra, Monica Schueller, Melissa Hilton and Kimberly Ridenour

Aims and objectives. This article presents an integrative review of the evidence for combined motivational interviewing and cognitive behavioural interventions that promote medication adherence. We undertook this review to establish a scientific foundation for development of interventions to promote medication adherence and to guide clinical practice. Background. The World Health Organization has designated medication adherence as a global problem. Motivational interviewing and cognitive behaviour interventions have been found to individually promote medication adherence. However, there is a gap in the literature on the effect of combined motivational interviewing and cognitive behavioural approaches to promote medication adherence. Design. Integrative review. Methods. COCHRANE, PubMed and CINAHL were searched to access relevant studies between 2004–2014. Inclusion criteria were interventions combining motivational interviewing and cognitive behavioural therapy with medication adherence as the outcome. Articles were assessed for measures of adherence and methodological rigour. Analysis was performed using an integrative review process. Results. Six articles met the inclusion criteria. A randomised controlled trial reported pretreatment missed doses of 558 and post-treatment of 092 and trended towards significance. Four cohort studies had effect sizes of 019–035 (p < 005). A case study had a pretreatment adherence rate of 25% and post-treatment 77% (p < 001). Conclusions. Although there were a limited number of studies on combined motivational interviewing and cognitive behavioural interventions, five out of six were effective at improving medication adherence. Future studies with large rigorous randomised trials are needed. Relevance to clinical practice. This review provides clinicians with the state of the science in relation to combined motivational interviewing and cognitive behavioural therapy interventions that promote medication adherence. A summary of intervention components and talking points are provided to aid nurses in informing decision-making and translating evidence into practice.

What does this paper contribute to the wider global clinical community?

• Reporting on how motivational



interviewing and cognitive behavioural therapy promote medication adherence rates. Providing talking points for nurses regarding interactions with patients using motivational interviewing and cognitive behavioural therapy to promote medication adherence.

Key words: cognitive behavioural therapy, integrative review, intervention, medication adherence, motivational interviewing Accepted for publication: 12 October 2014 Authors: Sandra L Spoelstra, PhD, RN, Assistant Professor, Michigan State University College of Nursing, East Lansing, MI; Monica Schueller, BA, Project Manager, Michigan State University College of Nursing, East Lansing, MI; Melissa Hilton, BSN, RN, Graduate Nursing Student, Research Assistant, Michigan State University College of Nursing, East Lansing, MI; Kimberly Ridenour, Undergraduate Nur-

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1163–1173, doi: 10.1111/jocn.12738

sing Student, Nurse Scholar, Research Assistant, Michigan State University College of Nursing, East Lansing, MI, USA Correspondence: Sandra Spoelstra, Assistant Professor, Michigan State University College of Nursing, 1355 Bogue Street, Room C342, East Lansing, MI 48824, USA. Telephone: +1 517-353-8681. E-mail: [email protected]

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for important intellectual content and (3) final approval of the version to be published.

Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author. html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically

Conflict of interest All authors indicate no conflict of interest or competing interests.

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Interventions combining motivational interviewing and cognitive behaviour to promote medication adherence: a literature review.

This article presents an integrative review of the evidence for combined motivational interviewing and cognitive behavioural interventions that promot...
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