New community pharmacy-led trial service aims to improve medication adherence in people with diabetes mellitus

Diabetes mellitus is a chronic disease and, globally, one of the most frequently reported causes of death​[1]​​[2]​. In the UK, more than three million people were diagnosed with diabetes in 2017, 90% of whom have type 2 diabetes mellitus (T2DM)​[3]​. T2DM management is affected by a several factors, including medication adherence​[4]​. Despite the benefits of medication adherence in reducing diabetes-associated complications and healthcare costs, poor adherence remains a common problem​[5–8]​. Half of all medications for chronic diseases are not being taken as prescribed and adherence rates for T2DM have been reported to be as low as 36% for some patients​[9–11]​.

Medication adherence is a complex health behaviour that is influenced by several factors, including regimen complexity and the patient’s ability to remember to take medications​[12–15]​. Given the diverse aetiologies accounting for medication non-adherence, it is unsurprising that interventions used to improve adherence are varied, complex and abundant​[16]​.                       

Systematic reviews of medication adherence demonstrate the wide variety of interventions used and that no gold standard intervention has yet been identified​[17]​. A 2020 systematic review highlighted that the evidence is dominated by interventions to address only the practical barriers to adherence; the most frequently reported interventions were dose simplification, education, and use of reminders​[16]​. In contrast, there is a growing body of evidence that barriers to adherence extend beyond the practicalities of forgetfulness, confusion and insufficient knowledge. A review of barriers to adherence, underpinned by behaviour change theory and refined after focus groups with patients, reported barriers far removed from the practicalities mainly addressed by existing interventions. Patients reported powerful negative emotions evoked by taking medicine, such as embarrassment and medicines being an unwelcome reminder of their illness. These emotions are likely to be exacerbated by interventions such as multi-compartment medication organisers and education, hence the need to fully understand a patient’s barriers to adherence, and work with them to formulate strategies that are acceptable and target the main barriers. The Identification of Medication Adherence Barriers Questionnaire (IMAB-Q) and associated Medication Adherence Support Decision Aid (MASDA) are freely available resources to support practitioners to work with patients to select the most appropriate adherence intervention(s)​[18,19]​.

Interventions aimed at improving medication adherence may not only target patients, but also practitioners, carers, family members or a combination of these​[20]​. A Cochrane review identified that allied health professionals, such as pharmacists, could help in overcoming the barriers of medication adherence and tailoring support to meet the needs of individual patients ​[10]​. In January 2021, we launched a pharmacist-led intervention for improving treatment adherence in people with diabetes mellitus (INTENSE). This COVID-safe trial represents an exciting opportunity for community pharmacies and general practices to collaborate and improve medication adherence. The trial is testing the effects of an intervention designed to provide personalised support for patients to take their T2DM medication as prescribed. The role of general practices is to invite patients to contact the community pharmacy. The role of community pharmacy is to deliver the intervention by working with patients to develop a tailored strategy to support adherence. The intervention combines a range of evidence-based approaches to improve adherence, including smart messages and an online self-help application for patients with low mood. The trial is open to recruit community pharmacies and their associated general practices.

For further information, contact Hiyam Al-Jabr at h.al-jabr@uea.ac.uk.

Hiyam Al-Jabr is senior research associate, School of Pharmacy, University of East Anglia; Andrew Farmer is professor of general practice, Nuffield Department of Primary Care Health Sciences, University of Oxford; Debi Bhattacharya is professor of behavioural medicine, School of Pharmacy, University of East Anglia.