Identifying the determinants of adjuvant hormonal therapy medication taking behaviour in women with stages I-III breast cancer: A systematic review and meta-analysis

Objective: This systematic review and meta-analysis aimed to identify the modifiable determinants of adjuvant hormonal therapy medication taking behaviour (MTB) in women with stage I-III breast cancer in clinical practice settings. Methods: We searched PubMed EMBASE, PsycINFO and CINAHL for articles investigating determinants of adjuvant hormonal therapy. Potentially modifiable determinants were identified and mapped to the 14 domains of the Theoretical Domains Framework (TDF), an integrative framework of theories of behavioural change. Meta-analysis was used to calculate pooled odds ratios for selected determinants. Results: Potentially modifiable determinants were identified in 42 studies and mapped to 9 TDF domains. In meta-analysis treatment side-effects (Domain: Beliefs about Capabilities) and follow-up care with a general practitioner (vs. oncologist) (Social Influences) were significantly negatively associated with persistence (p<0.001) and number of medications (Behaviour Regulation) was significantly positively associated with persistence (p<0.003). Studies did not examine several domains (including Beliefs about Consequences, Intentions, Goals, Social Identity, Emotion and Knowledge) which have been reported to influence MTB in other disease groups. Conclusions: There is some evidence that the domains Beliefs about Capabilities, Behaviour Regulation and Social Influences influence hormonal therapy MTB. Practice implications: Further research is needed to develop effective interventions to improve hormonal therapy MTB

Development of the HT&Me intervention to support women with breast cancer to adhere to adjuvant endocrine therapy and improve quality of life.

BACKGROUND: Breast cancer is the most common cancer in women worldwide. Approximately 80% of breast cancers are oestrogen receptor positive (ER+). Patients treated surgically are usually recommended adjuvant endocrine therapy (AET) for 5-10 years. AET significantly reduces recurrence, but up to 50% of women do not take it as prescribed. OBJECTIVE: To co-design and develop an intervention to support AET adherence and improve health-related quality-of-life (QoL) in women with breast cancer. METHODS: Design and development of the HT&Me intervention took a person-based approach and was guided by the Medical Research Council framework for complex interventions, based on evidence and underpinned by theory. Literature reviews, behavioural analysis, and extensive key stakeholder involvement informed 'guiding principles' and the intervention logic model. Using co-design principles, a prototype intervention was developed and refined. RESULTS: The blended tailored HT&Me intervention supports women to self-manage their AET. It comprises initial and follow-up consultations with a trained nurse, supported with an animation video, a web-app and ongoing motivational 'nudge' messages. It addresses perceptual (e.g. doubts about necessity, treatment concerns) and practical (e.g. forgetting) barriers to adherence and provides information, support and behaviour change techniques to improve QoL. Iterative patient feedback maximised feasibility, acceptability, and likelihood of maintaining adherence; health professional feedback maximised likelihood of scalability. CONCLUSIONS: HT&Me has been systematically and rigorously developed to promote AET adherence and improve QoL, and is complemented with a logic model documenting hypothesized mechanisms of action. An ongoing feasibility trial will inform a future randomised control trial of effectiveness and cost-effectiveness

A hard pill to swallow: a qualitative study of women’s experiences of adjuvant endocrine therapy for breast cancer

Objective: To explore women’s experiences of taking adjuvant endocrine therapy as a treatment for breast cancer and how their beliefs about the purpose of the medication, side effects experienced and interactions with health professionals might influence adherence. Design: Qualitative study using semistructured, one-to-one interviews. Setting: 2 hospitals from a single health board in Scotland. Participants: 30 women who had been prescribed tamoxifen or aromatase inhibitors (anastrozole or letrozole) and had been taking this medication for 1–5 years. Results: Women clearly wished to take their adjuvant endocrine therapy medication as prescribed, believing that it offered them protection against breast cancer recurrence. However, some women missed tablets and did not recognise that this could reduce the efficacy of the treatment. Women did not perceive that healthcare professionals were routinely or systematically monitoring their adherence. Side effects were common and impacted greatly on the women’s quality of life but did not always cause women to stop taking their medication, or to seek advice about reducing the side effects they experienced. Few were offered the opportunity to discuss the impact of side effects or the potential options available. Conclusions: Although most women in this study took adjuvant endocrine therapy as prescribed, many endured a range of side effects, often without seeking help. Advice, support and monitoring for adherence are not routinely offered in conventional follow-up settings. Women deserve more opportunity to discuss the pros, cons and impact of long-term adjuvant endocrine therapy. New service models are needed to support adherence, enhance quality of life and ultimately improve survival. These should ideally be community based, in order to promote self-management in the longer term

Supporting adjuvant endocrine therapy adherence in women with breast cancer : the development of a complex behavioural intervention using Intervention Mapping guided by the Multiphase Optimisation Strategy

Background: Adjuvant endocrine therapy (AET) reduces the risk of breast cancer recurrence and mortality. However, up to three-quarters of women with breast cancer do not take AET as prescribed. Existing interventions to support adherence to AET have largely been unsuccessful, and have not focused on the most salient barriers to adherence. This paper describes the process of developing four theory-based intervention components to support adherence to AET. Our aim is to provide an exemplar of intervention development using Intervention Mapping (IM) with guidance from the Multiphase Optimisation Strategy (MOST). Methods: Iterative development followed the six-stage IM framework with stakeholder involvement. Stage 1 involved a literature review of barriers to adherence and existing interventions, which informed the intervention objectives outlined in Stage 2. Stage 3 identified relevant theoretical considerations and practical strategies for supporting adherence. Stage 4 used information from Stages 1-3 to develop the intervention components. Stages 1-4 informed a conceptual model for the intervention package. Stages 5 and 6 detailed implementation considerations and evaluation plans for the intervention package, respectively. Results: The final intervention package comprised four individual intervention components: Short Message Service to encourage habitual behaviours surrounding medication taking; an information leaflet to target unhelpful beliefs about AET; remotely delivered Acceptance and Commitment Therapy-based guided self-help to reduce psychological distress; and a website to support self-management of AET side-effects. Considerations for implementation within the NHS, including cost, timing and mode of delivery were outlined, with explanation as to how using MOST can aid this. We detail our plans for the final stage of IM which involve feasibility testing. This involved planning an external exploratory pilot trial using a 24-1 fractional factorial design, and a process evaluation to assess acceptability and fidelity of intervention components. Conclusions: We have described a systematic and logical approach for developing a theoretically informed intervention package to support medication adherence in women with breast cancer using AET. Further research to optimise the intervention package, guided by MOST, has the potential to lead to more effective, efficient and scalable interventions

Medication Non-Adherence in Rheumatology, Oncology and Cardiology: A Review of the Literature of Risk Factors and Potential Interventions

Medication adherence is directly associated with health outcomes. Adherence has been reviewed extensively; however, most studies provide a narrow scope of the problem, covering a specific disease or treatment. This project’s objective was to identify risk factors for non-adherence in the fields of rheumatology, oncology, and cardiology as well as potential interventions to improve adherence and their association with the risk factors. The project was developed in three phases and carried out by a Steering Committee made up of experts from the fields of rheumatology, oncology, cardiology, general medicine, and hospital and community pharmacy. In phase 1, a bibliographic review was performed, and the articles/reviews were classified according to the authors’ level of confidence in the results and their clinical relevance. In phase 2, 20 risk factors for non-adherence were identified from these articles/reviews and agreed upon in Steering Committee meetings. In phase 3, potential interventions for improving adherence were also identified and agreed upon. The results obtained show that adherence is a dynamic concept that can change throughout the course of the disease, the treatments, and other factors. Educational interventions are the most studied ones and have the highest level of confidence in the authors’ opinion. Information and education are essential to improve adherence in all patients

Theory guided integrative systematic review of the psychosocial determinants associated with non-adherence to adjuvant hormonal therapy among breast cancer population

BACKGROUND: Suboptimal adherence to 5 years adjuvant hormonal therapy (AHT) is prevalent among people with breast cancer. Non-adherence to prescribed AHT medication is linked to increased recurrence rates, lower survival rates and wasted healthcare resources. Targeting the modifiable psychosocial factors has been heralded as a means to improve the phenomenon of suboptimal medication-taking behaviour. This thesis aims to conduct a theory-guided integrative systematic review to identify (I) psychosocial factors that are associated with treatment initiation, adherence, persistence and premature discontinuation, (II) modifiable barriers and facilitators of medication-taking behaviour and (III) intervention strategies that can be used to target the psychosocial barriers. METHOD: This integrative review follows PRISMA-P guidance and the review protocol was registered in PROSPERO (CRD42018102035). Systematic searches were conducted in 7 databases (MEDLINE, EMBASE, Web of Science Cochrane Library, CENTRAL, PsycINFO, PsycARTICLE and CINAHL). Only studies that addressed the following are eligible for inclusion: (I) examined associations between cognitive, behavioural, emotional, or social factors with non-initiation, non-adherence, non-persistence or discontinuation (II) published from 1998- 2018 papers and (III) study population that have clinically diagnosed breast cancer patient groups. Mixed Methods Appraisal Tool (version 2018) was used to access the quality of the included evidence. The Behaviour Change Wheel (BCW), made up of an inner layer of Theoretical Domains Framework (TDF), middle layer of Capabilities, Opportunities, Motivation and Behaviour (COM-B), and circled by a layer of intervention functions, was used to structure the design and analysis of the three research questions. TDF was used to frame the behavioural subgroup analysis, anchor the results, COM-B model and intervention functions were subsequently used to map the identified barriers with the intervention options and solution. RESULT: Of the 1229 papers screened, 58 articles (43 quantitative studies, 13 qualitative studies and 2 mixed method studies) were included and analyzed. TDF collated the key psychosocial factors from the included studies into 11 domains (Knowledge; Skills; Beliefs about capabilities; Beliefs about Consequences; Reinforcement; Intention and goals, Memory, attention and decision process; Environmental contexts and resources; Social Influences; Emotion; and Behavioural regulation). In conformity with the TDF result, COM- B model has identified the psychological capabilities (knowledge of side effects, memory, decision making), reflective motivation (perceptions and expectations, behavioural barriers), automatic motivation (intention, negative emotion), physical opportunity (resources) and social opportunity (clinical support) as the modifiable components. Based on the collective findings of the TDF and COM-B model, 4 intervention functions (Education, Persuasion, Training, Enablement) were matched into the relative components. CONCLUSION: This review is novel as it proposes a multilayer psychological understanding of nonadherence behaviour and provides a thorough overview of the behaviour change techniques that help to formulate future interventions. The cornerstone to improving optimal medication-taking behaviour is to educate patients on the knowledge of side effects seek to adjust the patients’ psychological adaptation and provide communication skills training among healthcare providers. These results are pertinent to healthcare providers, researchers and stakeholders who are likely to initiate interventions

Medication nonadherence: health impact, prevalence, correlates and interventions

Nonadherence to medicines is a global problem compromising health and economic outcomes for individuals and society. This article outlines how adherence is defined and measured, and examines the impact, prevalence and determinants of nonadherence. It also discusses how a psychosocial perspective can inform the development of interventions to optimise adherence and presents a series of recommendations for future research to overcome common limitations associated with the medication nonadherence literature. Nonadherence is best understood in terms of the interactions between an individual and a specific disease/treatment, within a social and environmental context. Adherence is a product of motivation and ability. Motivation comprises conscious decision-making processes but also from more 'instinctive', intuitive and habitual processes. Ability comprises the physical and psychological skills needed to adhere. Both motivation and ability are influenced by environmental and social factors which influence the opportunity to adhere as well as triggers or cues to actions which may be internal (e.g. experiencing symptoms) or external (e.g. receiving a reminder). Systematic reviews of adherence interventions show that effective solutions are elusive, partly because few have a strong theoretical basis. Adherence support targeted at the level of individuals will be more effective if it is tailored to address the specific perceptions (e.g. beliefs about illness and treatment) and practicalities (e.g. capability and resources) influencing individuals' motivation and ability to adhere

Development of the HT&Me intervention to support women with breast cancer to adhere to adjuvant endocrine therapy and improve quality of life

Background. Breast cancer is the most common cancer in women worldwide. Approximately 80% of breast cancers are oestrogen receptor positive (ER+). Patients treated surgically are usually recommended adjuvant endocrine therapy (AET) for 5–10 years. AET significantly reduces recurrence, but up to 50% of women do not take it as prescribed. Objective. To co-design and develop an intervention to support AET adherence and improve health-related quality-of-life (QoL) in women with breast cancer. Methods. Design and development of the HT&Me intervention took a person-based approach and was guided by the Medical Research Council framework for complex interventions, based on evidence and underpinned by theory. Literature reviews, behavioural analysis, and extensive key stakeholder involvement informed ‘guiding principles’ and the intervention logic model. Using co-design principles, a prototype intervention was developed and refined. Results. The blended tailored HT&Me intervention supports women to self-manage their AET. It comprises initial and follow-up consultations with a trained nurse, supported with an animation video, a web-app and ongoing motivational ‘nudge’ messages. It addresses perceptual (e.g. doubts about necessity, treatment concerns) and practical (e.g. forgetting) barriers to adherence and provides information, support and behaviour change techniques to improve QoL. Iterative patient feedback maximised feasibility, acceptability, and likelihood of maintaining adherence; health professional feedback maximised likelihood of scalability. Conclusions. HT&Me has been systematically and rigorously developed to promote AET adherence and improve QoL, and is complemented with a logic model documenting hypothesized mechanisms of action. An ongoing feasibility trial will inform a future randomised control trial of effectiveness and cost-effectiveness

The RESILIENT Study: A Retrospective, Descriptive, Correlational Investigation of Rate and Correlates of Oral Endocrine Therapy Adherence in Older Women with Breast Cancer

Title from PDF of title page, viewed September 18, 2023Dissertation advisor: Cynthia L. RussellVitaIncludes bibliographical references (pages 225-273)Dissertation (Ph.D.)--School of Nursing and Health Studies. University of Missouri--Kansas City, 2023Breast cancer is the most prevalent and costly cancer among females. About 80% of breast cancer patients take oral endocrine therapy (OET), such as anastrozole, letrozole, tamoxifen, and exmestane. These medications increase survival, improve quality-of-life and decrease healthcare costs, yet many patients do not take it properly. The purpose of this study is to identify rates of and multi-level determinants influencing OET non-adherence (NA) among older women with breast cancer enrolled in Medicare Part-D. It is important to consider older women with breast cancer; the medium breast cancer patient age was 62 and more than 20% of newly diagnosed patients were older than 70 in 2021. Most existing research on OET-NA has been conducted on small samples at single sites and has focused predominantly on patient issues rather than exploring multi-level determinants. Despite their unique needs due to aging effects, there are no specific guidelines or known OET-NA determinants for older women with breast cancer. To resolve this, I utilized a large data set with theoretical frameworks (World Health Organization’s five-dimensional-model of factors and Bronfenbrenner’s ecological system theory) to understand multi-level determinants through a secondary data analysis of the Surveillance-Epidemiology-End-Results Medicare database (average age 69). All women in the database with a cancer diagnosis were identified using ICD-9 and ICD-10 codes in Medicare Part-D to identify ten years of OET-NA rates. I then focused on the most recently released data from 2019 to identify up-to-date trends in OET-NA determinants. Results demonstrated that OET-NA was significantly affected by (a) patient-related factors of ethnicity and psychological issues, (b) socioeconomic-related factors of marital status, and lifestyle, (c) therapy-related factors of switching OET medications and increased number of drug therapy experiences, (d) condition-related factors of cancer stage and comorbidities, and (e) health care team/system-related factors of characteristics of healthcare team and system. The first steps in developing interventions for better nursing practice based on strong theoretical frameworks were determining rates and multi-level determinants of OET-NA on older women. This study can also support the implementation of better nursing policies to improve patient education and OET adherence— ultimately decreasing morbidity and mortality, and increasing quality-of-life.Introduction -- Literature review -- Methods -- Results -- Discussio