Factors associated with non-adherence to pharmacotherapy in older people in primary health care in Brazil: a systematic review

Silva, William Lucas Ferreira da; Gomes, Leonardo Campos; Silvério, Marcelo Silva; Cruz, Danielle Teles da

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Revista Brasileira de Geriatria e Gerontologia

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Review Articles • Rev. bras. geriatr. gerontol. 24 (4) • 2021 • https://doi.org/10.1590/1981-22562021024.210156 copy

Factors associated with non-adherence to pharmacotherapy in older people in primary health care in Brazil: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives

To identify the factors associated with non-adherence to pharmacotherapy in elderly Brazilians assisted by Primary Health Care (PHC) through a systematic review of the literature.

Method

This is a systematic literature review in English, Spanish, and Portuguese, performed in the SciELO electronic library and in the electronic databases MEDLINE - via PubMed, LILACS, Embase, and Web of Science from January 2010 to June 2020. Study selection was performed independently by two reviewers using the Rayyan selection application.

Results

After applying the eligibility criteria, nine studies were included in the systematic review. The most frequent method used to measure the outcome was the Morisky-Green Scale (4-items). The results point that the main factors related to non-adherence to pharmacotherapy in PHC are difficulties in medication access, multimorbidities, polypharmacy, the use of potentially inappropriate medications for the elderly, the degree of trust in the medical professional, beliefs, negative self-perception of health and functional disability.

Conclusions

In the context of PHC, non-adherence to pharmacotherapy by the elderly population presents itself as a very frequent problem, being triggered by multiple factors and with negative consequences for the control of health conditions, the rational use of medications, and healthy aging. It is also noteworthy that part of the associated factors are subject to intervention at this level of health care.

Keywords
Aging; Health of the elderly; Primary Health Care; Pharmaceutical Assistance; Adherence to pharmacological treatment

Author, year, place of study, and journal	Research design	Sociodemographic characterization, health, and behavioral profile
Aiolfi et al., 2015 Dourados (MS) Revista Brasileira de Geriatria e Gerontologia¹⁰10 Aiolfi CR, Alvarenga MRM, Moura CS, Renovato RD. Adesão ao uso de medicamentos entre idosos hipertensos. Rev Bras Geriatr Gerontol. 2015;18(2):397-404.	Cross-sectional study.	N = 124
		Gender: male (32.3%) and female (67.7%)
		Age: 71 years and over (55.64%)
		Education: illiterate (38.70%)
		Family arrangement: accompanied (79.83%)
		Self-rated health: bad/very bad: (12,1%)
		Per capita income: up to one minimum wage (73.3%)
		Medications per day: 4 or more (59.68%)
		Health diagnoses: 3 or more (58.87%)
		Cognitive deficit (61.29%)
Borba et al., 2018 Recife (PE) Science & Public Health¹¹11 Borba AKOT, Marques APO, Ramos VP, Leal MCC, de Arruda IKG, Ramos RSPS. Fatores associados à adesão terapêutica em idosos diabéticos assistidos na atenção primária de saúde. Ciênc Saúde Colet. 2018;23(3):953-61.	Cross-sectional study	N = 150
		Gender: male (26.7%) and female (73.3%)
		Age: 60 to 69 years (54.7%)
		Education: up to 8 years of study (58.7%)
		Family arrangement: spouse + family members (60%)
		Self-perceived health: regular (62%) and poor (12%)
		Monthly income of the older person: from one to two minimum wages (52.7%)
Obreli-Neto et. al., 2010 Salto Grande (SP)¹²12 Obreli-Neto PR, Prado MF, Vieira JC, Fachini FC, Pelloso SM, Marcon SS, et al. Fatores interferentes na taxa de adesão à farmacoterapia em idosos atendidos na rede pública de saúde do Município de Salto Grande – SP, Brasil. Rev Ciênc Farm Básica Apl. 2010;31(5790):229-33. Revista de Ciências Farmacêuticas Básica e Aplicada¹²12 Obreli-Neto PR, Prado MF, Vieira JC, Fachini FC, Pelloso SM, Marcon SS, et al. Fatores interferentes na taxa de adesão à farmacoterapia em idosos atendidos na rede pública de saúde do Município de Salto Grande – SP, Brasil. Rev Ciênc Farm Básica Apl. 2010;31(5790):229-33.	Cross-sectional study	N = 102
		Gender: male (38.3%) and female (61.7%)
		Age: average 64.7 years old
		Education: incomplete elementary education (76.5%)
		Monthly Family Income: average of one minimum wage
		Color: black (68.6%)
		Dissatisfaction with UBS: 66,7%
		Average number of reported diseases: 2,4
Saraiva et al., 2020 Crato (CE) Journal of Diabetes e Metabolic Disorders¹³13 Saraiva EMS, Coelho JLG, Figueiredo FWS, do Souto RP. Medication non-adherence in patients with type 2 diabetes mellitus with full access to medicines. J Diabetes Metab Disord. 2020;19(2):1105-13.	Cross-sectional study	N = 300
		Gender: male (35.7%) and female (64.3%)
		Age: average 61 years old
		Education: up to 8 years of study (65%)
		Marital status: married (69.7%)
		Monthly Family Income: up to 1 minimum wage (65%)
		Regular practice of physical activity: 40.3%
		Number of chronic complications: 1 to 2 (52.7%)
Schmitt Júnior, Lindner, Santa Helena, 2013 Blumenau (SC) Revista de Associação Médica¹⁴14 Schmitt Jr. AA, Lindner S, de Santa Helena ET. Assessment of adherence in elderly patients in primary care. Rev Assoc Med Bras. 2013;59(6):614-21.	Cross-sectional study	N = 150
		Gender: male (27.8%) and female (72.2%)
		Age: 60 to 69 years (62.9%)
		Education: 3 to 4 years of study (45.7%)
		Color: White (81.2%)
		Marital status: married/common-law marriage (47%)
		Number of medications: 5 or more (43%)
		Prescription of inappropriate medications for older people (16.6%)
Silva et al., 2014 Londrina (PR) Revista de Ciências Farmacêuticas Básica e Aplicada¹⁵15 Silva LFRS, Marino JMR, Guidoni CM, Girotto E. Fatores associados à adessão ao tratamento anti-hipertensivo por idosos na atenção primária. Rev Ciênc Farm Básica Apl. 2014;35(2):269-76.	Cross-sectional study	N = 117
		Gender: male (35.7%) and female (65%)
		Age: 60 to 69 years (45.3%)
		Education: up to 7 years of study (65%)
		Color: White (70.9%)
		Self-perceived health: bad or very bad (13.7%)
		Does not practice any physical activity (65%)
Stefano et al., 2017 Marília (SP) Revista Brasileira de Geriatria e Gerontologia¹⁶16 Stefano ICA, Conterno LO, da Silva Filho CR, Marin MJS. Medication use by the elderly: analysis of prescribing, dispensing, and use in a medium-sized city in the state of São Paulo. Rev Bras Geriatr Gerontol. 2017;20(5):679-90.	Cross-sectional study	N = 150
		Gender: male (35.7%) and female (62,3%)
		Age: 60 to 69 years (53.5%)
		Education: up to 4 years of study (57,9%)
		Marital status: married/common-law marriage (49,1%)
		Retired or pensioners (78.9%)
Tavares et al, 2013 Bagé (RS) Revista de Saúde Pública¹⁷17 Tavares NUL, Bertoldi AD, Thumé E, Facchini LA, de França GVA, Mengue SS. Factors associated with low adherence to medication in older adults. Rev Saúde Pública. 2013;47(6):1092-101.	Cross-sectional study	N = 1242
		Gender: male (35.7%) and female (62,3%)
		Age: 65 to 74 years (45.3%)
		Education: 55.7% (up to 7 years of study)
		Socioeconomic status: C (39.5%)
		Self-perceived health: regular/bad/very bad (40.6%)
		Cognitive Deficit (13.4%)
		Disability for Instrumental Activities of Daily Living (34.6%)
		Number of reported morbidities: 3 or more (30.4%)
Ungari, Amauri, 2010 Ribeirão Preto (SP) Brazilian Journal Pharmaceutical Sciences¹⁸18 Ungari AQ, Fabbro AL. Adherence to drug treatment in hypertensive patients on the Family Health Program. Brazilian J Pharm Sci. 2010;46(4):811-8.	Cross-sectional study	N = 109
		Gender: male (15.6%) and female (84.4%)
		Age: 60 years and over (55.1%)
		Education: up to 8 years of study (75.35)
		Marital status: married (56%)
		Color: White (81.7%)
		Does not practice any physical activity (50.5%)

Author and Year	Quality Score	Assessment
Aiolfi et al., 2015.¹⁰10 Aiolfi CR, Alvarenga MRM, Moura CS, Renovato RD. Adesão ao uso de medicamentos entre idosos hipertensos. Rev Bras Geriatr Gerontol. 2015;18(2):397-404.	7	High Quality
Borba et al., 2018.¹¹11 Borba AKOT, Marques APO, Ramos VP, Leal MCC, de Arruda IKG, Ramos RSPS. Fatores associados à adesão terapêutica em idosos diabéticos assistidos na atenção primária de saúde. Ciênc Saúde Colet. 2018;23(3):953-61.	7	High Quality
Obreli-Neto et. al., 2010.¹²12 Obreli-Neto PR, Prado MF, Vieira JC, Fachini FC, Pelloso SM, Marcon SS, et al. Fatores interferentes na taxa de adesão à farmacoterapia em idosos atendidos na rede pública de saúde do Município de Salto Grande – SP, Brasil. Rev Ciênc Farm Básica Apl. 2010;31(5790):229-33.	7	High Quality
Saraiva et al., 2020.¹³13 Saraiva EMS, Coelho JLG, Figueiredo FWS, do Souto RP. Medication non-adherence in patients with type 2 diabetes mellitus with full access to medicines. J Diabetes Metab Disord. 2020;19(2):1105-13.	7	High Quality
Schmitt Júnior, Lindner, Santa Helena, 2013.¹⁴14 Schmitt Jr. AA, Lindner S, de Santa Helena ET. Assessment of adherence in elderly patients in primary care. Rev Assoc Med Bras. 2013;59(6):614-21.	8	High Quality
Silva et al., 2014.¹⁵15 Silva LFRS, Marino JMR, Guidoni CM, Girotto E. Fatores associados à adessão ao tratamento anti-hipertensivo por idosos na atenção primária. Rev Ciênc Farm Básica Apl. 2014;35(2):269-76.	8	High Quality
Stefano et al., 2017.¹⁶16 Stefano ICA, Conterno LO, da Silva Filho CR, Marin MJS. Medication use by the elderly: analysis of prescribing, dispensing, and use in a medium-sized city in the state of São Paulo. Rev Bras Geriatr Gerontol. 2017;20(5):679-90.	7	High Quality
Tavares et al, 2013.¹⁷17 Tavares NUL, Bertoldi AD, Thumé E, Facchini LA, de França GVA, Mengue SS. Factors associated with low adherence to medication in older adults. Rev Saúde Pública. 2013;47(6):1092-101.	8	High Quality
Ungari, Fabbro, 2010.¹⁸18 Ungari AQ, Fabbro AL. Adherence to drug treatment in hypertensive patients on the Family Health Program. Brazilian J Pharm Sci. 2010;46(4):811-8.	7	High Quality

Author and Year	Assessment Method	Prevalence	Factors associated with non-pharmacological pharmacotherapy	Association measures and statistical significance
Aiolfi et al., 2015.¹⁰10 Aiolfi CR, Alvarenga MRM, Moura CS, Renovato RD. Adesão ao uso de medicamentos entre idosos hipertensos. Rev Bras Geriatr Gerontol. 2015;18(2):397-404.	8-item Morisky Medication Adherence Scale (MMAS-8)	68.5% (Non-Adherence)	Absence of cognitive deficit	PR= 1.28 (95% CI 1.02 - 1.61); p=0.003*
	8-item Morisky Medication Adherence Scale (MMAS-8)	68.5% (Non-Adherence)	Younger older people	PR= 1.62 (95% CI 1.27 - 2.01); p<0.001*
Borba et al., 2018.¹¹11 Borba AKOT, Marques APO, Ramos VP, Leal MCC, de Arruda IKG, Ramos RSPS. Fatores associados à adesão terapêutica em idosos diabéticos assistidos na atenção primária de saúde. Ciênc Saúde Colet. 2018;23(3):953-61.	Positive response to questions related to the use of medications	66.7% (Partial Adherence) and 6% (Non Adherence)	Beliefs related to the use of medications: For partial adherence For non-adherence	Adjusted OR = 9.65 (95% CI 1.6 - 56.6)**
				Adjusted OR = 18.15 (95% CI 3.5 - 95.4)**
				OR adjusted by the variables: self-perception of health, understanding the explanations about diabetes, and professional responsible for guiding treatment.
Obreli-Neto et. al., 2010.¹²12 Obreli-Neto PR, Prado MF, Vieira JC, Fachini FC, Pelloso SM, Marcon SS, et al. Fatores interferentes na taxa de adesão à farmacoterapia em idosos atendidos na rede pública de saúde do Município de Salto Grande – SP, Brasil. Rev Ciênc Farm Básica Apl. 2010;31(5790):229-33.	8-item Morisky Medication Adherence Scale (MMAS-8)	37.3% (Low adherence)	Patients' dissatisfaction with healthcare services	r=0.884; p<0.0001 **
			Medication Regimen Complexity Index	r=-0,705; p<0,0001 **
			Number of medications taken	r=-0,604; p<0,0001 **
			Number of diseases reported	r=-0,604; p<0,0001 **
			Number of residents per household	r= 0,328; p<0,0001**
Saraiva et al., 2020.¹³13 Saraiva EMS, Coelho JLG, Figueiredo FWS, do Souto RP. Medication non-adherence in patients with type 2 diabetes mellitus with full access to medicines. J Diabetes Metab Disord. 2020;19(2):1105-13.	Morisky-Green Scale (4 items) and Beliefs about Medicines Questionnaire (BMQ)	77.3% (Low adherence)	Marital Status (married)	RP= 1,27 (IC 95% 1,02 - 1.59) p=0,01 *
			Arterial hypertension	RP= 1,14 (IC 95% 0,99 - 1,32) p=0,03 *
			Does not practice physical activity regularly	RP= 1,16 (IC 95% 1,02 - 1.33) p=0,01 *
			Low belief in the need for medication	p=0,038**
Schmitt Júnior, Lindner, Santa Helena, 2013.¹⁴14 Schmitt Jr. AA, Lindner S, de Santa Helena ET. Assessment of adherence in elderly patients in primary care. Rev Assoc Med Bras. 2013;59(6):614-21.	Morisky-Green Scale (4 items)	35.4% (Non Adherence)	Previous interruption due to lack of medication	Adjusted OR = 2.9 (95% CI 1.3-6.9)p=0.01 **
			Prescription of inappropriate medications for older people	Adjusted OR = 2.9 (95% CI 1.1-7.9) p=0.03 **
				Adjusted OR for the variables: consumption class, how you feel about your treatment, and report of adverse reactions
Silva et al., 2014.¹⁵15 Silva LFRS, Marino JMR, Guidoni CM, Girotto E. Fatores associados à adessão ao tratamento anti-hipertensivo por idosos na atenção primária. Rev Ciênc Farm Básica Apl. 2014;35(2):269-76.	Morisky-Green Scale (4 items)	45.3% (Non adherence)	Male gender	p<0.05 / ***
	Morisky-Green Scale (4 items)	45.3% (Non adherence)	Older age (octogenarians)	p<0.01 / ***
Stefano et al., 2017.¹⁶16 Stefano ICA, Conterno LO, da Silva Filho CR, Marin MJS. Medication use by the elderly: analysis of prescribing, dispensing, and use in a medium-sized city in the state of São Paulo. Rev Bras Geriatr Gerontol. 2017;20(5):679-90.	Haynes and Morisky-Green Scale (4 items)	40.3% (Low adherence)	****	***
Tavares et al, 2013.¹⁷17 Tavares NUL, Bertoldi AD, Thumé E, Facchini LA, de França GVA, Mengue SS. Factors associated with low adherence to medication in older adults. Rev Saúde Pública. 2013;47(6):1092-101.	Brief Medication Questionnaire (BMQ)	32.9% likely low adherence and 1/3 low adherence.	Age between 65 and 74 years old	Adjusted PR= 1.25 (95% CI 1.00–1.56); p=0.052 **
			Does not have health insurance	Adjusted PR= 1.01 (95% CI 1.00); p=0.028 **
			Need to buy (in whole or in part) the medications	Adjusted PR= 1.07 (95% CI 0.86 – 1.33)p<0.001 **
			Presence of three or more morbidities	Adjusted PR= 1.39 (95% CI 1.06 – 1.82)p=0.004 **
			Present functional disability for instrumental activities of daily living	Adjusted PR= 1.25 (95% CI 1.05–1.49); p=0.009 **
			Greatest number of medications used	Adjusted PR= 10.18 (95% CI 5.65 – 18.33); p<0.001 **
				PR adjusted by the set of variables presented
Ungari, Fabbro, 2010.¹⁸18 Ungari AQ, Fabbro AL. Adherence to drug treatment in hypertensive patients on the Family Health Program. Brazilian J Pharm Sci. 2010;46(4):811-8.	Morisky-Green Scale (4 items)	Less adherent: 20.2% (Criterion 1) and 56.9% (Criterion 2)	Lower degree of trust in the healthcare professional	PR= 1.06 (95% CI 0.26 - 4.31); p=0.03 *
	Morisky-Green Scale (4 items)	Less adherent: 20.2% (Criterion 1) and 56.9% (Criterion 2)	Greater number of antihypertensive medications used	PR= 1.78 (95% CI 0.80 – 3.92); p=0.071*

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[1] Correspondence William Lucas Ferreira da Silva williamluccas@yahoo.com.br

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Factors associated with non-adherence to pharmacotherapy in older people in primary health care in Brazil: a systematic review

Abstract

﻿Objectives

Method

Results

Conclusions

Objectives