The development and evaluation of pharmacy-led medication adherence services

Keywords Medication adherence, pharmacy services, domiciliary medicines support, health behaviour change, cognitive-based techniques, theoretical domains framework. Background Medication non-adherence has been described as a worldwide problem of striking magnitude yet a gold-standard adherence intervention remains elusive and current interventions elicit modest improvements at best. Innovative, evidence-based approaches, grounded in theory and tailored to meet individual need are therefore required. Methods This thesis included four key elements: (1) a domiciliary medicines support service was evaluated to establish the effect of a pharmacy-led service targeting non-adherence of a primarily unintentional nature. (2) A review of health psychology theory was undertaken to provide a theoretical basis for intervention design. (3) A systematic review and metaanalysis of ‘cognitive-based’ behaviour change techniques designed to improve medication adherence was undertaken to identify effective behaviour change techniques for intentional non-adherence. (4) A theory-based questionnaire to identify barriers to medication adherence was developed as a precursor to an intervention to address patient identified barriers to medication adherence. Results Medication regimen simplification, provision of adherence support and implementation of care packages, appear to be effective in reducing patients’ medication related risk of harm and improving unintentional non-adherence in domiciliary support recipients. However, these findings should be interpreted cautiously due to the ‘before-and-after’ study design. ‘Cognitive-based’ interventions may be capable of eliciting improvements in adherence beyond those yielded with the behavioural and educational interventions that form the mainstay of current practice. The theoretical domains framework has been used successfully to develop a questionnaire to identify medication adherence barriers. Conclusions At present, pharmacy-led adherence interventions tend to focus on resolving adherence difficulties of a practical nature. Whilst these approaches are of some benefit to unintentional non-adherence, intentional non-adherence requires a different approach. ‘Cognitive-based’ behaviour change techniques such as motivational interviewing could be delivered in routine pharmacy consultations to address adherence barriers identified using a theory-based questionnaire.