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The American Journal of Managed Care December 2012
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Association Between Different Types of Social Support and Medication Adherence
Danielle Scheurer, MD, MSCR; Niteesh Choudhry, MD, PhD; Kellie A. Swanton, BA; Olga Matlin, PhD; and Will Shrank, MD, MSHS

Association Between Different Types of Social Support and Medication Adherence

Danielle Scheurer, MD, MSCR; Niteesh Choudhry, MD, PhD; Kellie A. Swanton, BA; Olga Matlin, PhD; and Will Shrank, MD, MSHS
Medication adherence is most closely associated with emotional and practical support.
Objectives: To evaluate the association between social support and medication adherence.


Study Design: A search of articles published before November 2010 in peer-reviewed, healthcarerelated journals was conducted using PubMed, EMBASE, and Web of Science, and search terms related to social support (social support OR friend OR family OR agency) and adherence (patient compliance OR medication adherence), yielding 5331 articles.


Methods: Articles were included if they directly measured the relationship between medication adherence and some form of social support. Excluded were case studies, studies with participants <18 years of age, and non–English language studies. Four social support categories were reported: structural, practical, emotional, and combination. Medication adherence was reported in the manner in which it was described in each study.


Results: Fifty studies were included in the final analysis. A greater degree of practical support was most consistently associated with greater adherence to medication; evidence for structural or emotional support was less compelling. However, most studies were limited in size and design, and substantial variability in designs and outcome measurement prohibited pooling of results, necessitating qualitative evaluation of the studies.


Conclusions: This qualitative analysis found that practical social support was most consistently associated with greater medication adherence. Interventions that use existing contacts (friends or family) to engage patients in the mundane and practical aspects of medication purchasing and administration may be an effective approach to promoting better medication adherence.


(Am J Manag Care. 2012;18(12):e461-e467)
This qualitative analysis found that practical social support is consistently associated with higher medication adherence.

  •  Medication adherence is most closely associated with having a repertoire of close friends or providers who can consistently provide emotional and practical support that does not leave the patient with the perception of unmet needs.

  •  Providing people in the patient’s social network with emotional and practical skills (eg, focused on medication adherence, barriers, support, and confidence building) may have a significant impact on medication adherence.
Nonadherence to chronic medications imposes a substantial clinical and financial burden on the US healthcare system. Studies have repeatedly demonstrated that medication nonadherence is a common source of hospitalizations, morbidity, and mortality in a variety of populations and disease states.1-3 The financial consequences of medication nonadherence in the United States are tremendous; the cost of care for patients with cardiovascular disease and diabetes are substantially greater in those who do not adhere to therapy than in those who do adhere, and total annual costs of medication nonadherence are estimated at almost $300 billion in the United States.3,4

Despite the importance of medication nonadherence, no simple solutions are available to fix the problem.5 Numerous studies have aimed to improve medication adherence, yet best practices to enhance better medication taking continue to evolve.4-6 Moreover, little is known about the most cost-effective interventions to encourage better adherence.7 Therefore, new, low-cost approaches to improve medication adherence are needed to promote improved health outcomes and reduce healthcare costs.

The emergence of popular online social networking websites has stimulated interest in the role of social capital or connectedness in promoting health. Greater social support has been shown to be associated with improved health outcomes and healthier behavior.8 Yet the role of one’s social connectedness in medication adherence has not been well defined. Considering that social support connections are wide ranging, encompassing many aspects of the relationship between the patient and the person providing the support, we know even less about how different features of one’s social support system can influence medication use.

Accordingly, we conducted a systematic review of the published literature to evaluate what is known about the association between social support and medication adherence in a variety of disease states, and to explore features of one’s social support that might encourage better behavior. To do so, we categorized social support structures into those that are more functional and those that are predominantly emotional in nature.9,10 We aimed to evaluate the relative influence of the various types of support on medication adherence, so that appropriate and effective interventions to improve medication adherence can be designed.

METHODS

Study Selection


With the help of a professional librarian, we performed a search of articles published before November 2010 in peerreviewed, healthcare-related journals using PubMed, EMBASE, and Web of Science. We used search terms related to social support (social support OR friend OR family OR agency) and adherence (patient compliance OR medication adherence). Articles with at least 1 search term from both categories met the criteria for the initial title/abstract review. After screening for duplicate entries, the results from the 3 databases were combined and totaled 5331 articles. Of these abstracts, 169 were included for full review of inclusion and exclusion criteria (Figure).

Articles were included if they directly measured the relationship between medication adherence and some form of social connectedness and/or support. There were 131 excluded articles, including case studies, studies with patients less than 18 years of age, non–English language publications, and studies where no medication-specific adherence measure was reported as an outcome (leaving 38 articles). Pediatric studies were excluded because the different mechanism and influence of social support in pediatric versus adult medication adherence would make conclusions difficult. The inclusion or exclusion of each article was determined by 2 reviewers independently, and disagreements were resolved by a third reviewer. All reference lists from the included articles were evaluated, and 12 additional studies (not found in our original search) were included, as determined by consensus. Data on study populations and characteristics, results, and study quality were extracted from each article using a standardized protocol and reporting form. Specific information collected included study population, social support measure, adherence measure, and adherence outcome.

Data Extraction

For our key explanatory variable, social support, we defined 4 categories: structural, practical, emotional, and combination, which are further defined with examples in the Table. Each social support item abstracted from an included study was placed into 1 of these 4 social support categories by 2 reviewers independently, and disagreements were resolved by a third reviewer. The combination category reflects those social support items or instruments that did not distinguish the precise type of support measured, or that only reported a summary measure that included multiple support types.

Our outcome variable, medication adherence, is reported in the manner it was described in each study (Appendix). Studies that reported more than 1 social support category are represented in more than 1 table in the Appendix.

RESULTS

Population


We included a total of 50 studies; 14 evaluated structural support, 12 practical support, 14 emotional support, and 26 combination support (Figure). Most were conducted in disease-specific populations; the most common were human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS), diabetes, dialysis, tuberculosis, cardiovascular (hypertension and congestive heart failure), asthma, and transplant. Most were cross-sectional observational studies. Sample sizes ranged from 26 to 1198 patients.

Social Support Measurements

Almost all included studies required participants to evaluate their perception of support; 2 interviewed caregivers.11,12 Approximately half used some variation of a previously validated instrument, and half used study-specific questionnaires. A majority utilized a self-completed survey instrument (n = 28), while fewer relied on interviews (n =16). The remainder utilized a combination of surveys and interviews, or did not describe the data collection. Most included several different types of support, while 17 measured only 1 type. Adherence was largely measured using subjective self-report, while 13 corroborated adherence objectively with pill count, refill information, or urine/serum markers of adherence.1,2,13-23 One study used a nurse assessment of adherence.24

Structural Support

We identified 14 studies that assessed the relationship between structural social support and medication adherence; this structural support was cohabitation in 4 studies,1,20,24,25 presence of a spouse or supportive relationship in 7 studies,22,26-31 and both in 2 studies.14,32 In 1 study, structural social support was defined by the size of patients’ social network (Table).9

Of all these studies, 6 (43%) identified an association between structural support and medication adherence, but some identified a positive association and others found a negative association. Two identified relationship status as significantly associated with being more adherent, with logistic regression coefficients of 1.2 (P  value not reported)26 and 2.7 (P = .02)32; however, a third study identified having a partner as being associated with lower odds of adherence compared with not having a partner (odds ratio [OR] of adherence 0.97, P <.01),28 and a fourth study found that adherence was highest in divorced persons.29 Living situation (eg, living with someone) had a negative association with adherence in 2 studies (both in an HIV population).24,32 Only 1 study found that living with a spouse or relative had a significant, but modest, association with adherence.20

Of the 8 (57%) studies that did not identify an association between structural support and medication adherence, 1,9,14,22,25,27,30,31 most evaluated marital status or living status. Two of these studies involved large cohorts of patients with objectively measured medication adherence.22,30 The 1 study that evaluated social network size did not identify a significant association with adherence, although it evaluated only frequency of contact, but not quality or type of the interaction.9

Practical Support

We identified 12 studies that assessed the relationship between practical social support and medication adherence. Practical support was assessed by subjective participant ratings about how much help they received or how satisfied they were with the help in 3 main areas: medication help (reminders to take medication, directive guidance on medications, picking up prescriptions), help with household functions (cooking, cleaning, paying bills, running errands), and help with transportation.

Of these 12 studies, 8 (67%) identified a significant association of help with adherence. Of those, all but 1 identified a significant positive association (either amount of support or satisfaction with support) with medication adherence.11,19,33-37 The 1 study that identified a negative association was a small study with an HIV cohort, where the adherence measure was nurse-perceived adherence, a poorly validated measure of actual medication use.24 Two studies analyzed the association using a multivariate technique. The first study found the number of sources of practical support was associated with adherence; having 1 source of support was not associated with higher adherence, but 2 or more sources were associated with twice the odds ofadherence compared with the adherence of patients with no sources of support (OR of adherence 2.12, 95% confidence interval [CI] 1.06-4.26; P = .004).36 In the second study, participants who had an “unmet need” for benefits (eg, Medicaid, Social Security, or prescription help) had an OR of nonadherence of 2.8 (P <.01) compared with patients who did not have this unmet need; 51% of the cohort reported needing help in this area. Other unmet practical needs were not associated with adherence (housing, emergency provisions, legal assistance, or supplemental nutrition), although about two-thirds of the cohort did not report a need in those areas.37

Of the 4 (33%) studies that did not identify an association, all were limited by very small sample sizes (58-112 patients), and subjective self-reports of both practical support and medication adherence.12,38-40

Emotional Support

Observational Studies. We identified 14 observational studies that assessed the relationship between emotional support and medication adherence. Emotional support was assessed by self-report in a variety of ways, including perceived amount of or satisfaction with social support, number of social support unmet needs, or the number of friends and social support sources.

 
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