Development and validation of the IMAB-Q Development and validation of the IMAB-Q

Many people face barriers to taking their medication regularly. It is estimated that between 30 and 50% of patients prescribed medication for long term conditions do not take them as prescribed. Barriers include practical difficulties (such as getting to the pharmacy or being unable to swallow medication) and/or perceptual barriers (such as lack of motivation or negative emotions). The result is poorer patient health, increased medication wastage, and investigations and prescribing that may otherwise have been avoided.

To provide the best support to help patients take their medication, their personal barrier(s) must firstly be identified. Research shows that identifying the underlying barriers is challenging for patients and practitioners.   The Identification of Medication Adherence Barriers Questionnaire (IMAB-Q) was developed and validated to support patients and practitioners to identify these barriers. The IMAB-Q was developed using the stages of literature search, mapping to a theoretical framework and focus groups with people prescribed medication.

Literature search

We searched the literature for known barriers to adherence experienced by people prescribed long-term medication. The search terms used for this scoping review are provided in table 1.

Table 1 Search strategy for scoping review informing the development of the IMAB-Q

  Search terms
1 Medication*.ti,ab OR Drug*.ti,ab OR Medicine*.ti,ab
2 Adheren*.ti,ab OR Complian*.ti,ab OR Concordan*.ti,ab OR Non-adheren*.ti,ab OR Non-complian*.ti,ab
3 Barrier*.ti OR Difficult*.ti OR Problem*.ti OR Reason*.ti (NOT Tissue.ti, NOT epithelial.ti, NOT cream*.ti, NOT skin.ti, NOT platelet.ti, NOT guideline*.ti)
4 1 AND 2 AND 3
5 4 NOT letter, NOT editorial, NOT comment

All of the barriers identified from this literature search were organised into similar themes. This initial pool of barriers and the 17 themes to which they were organised are provided in table 2.

Table 2. Preliminary pool of adherence barriers extracted from literature

Adherence barrier theme

Barriers included

Beliefs about medicines

Mistrust or beliefs

Suspicions about treatment

Not convinced of medicines efficacy

Uncertainty regarding long term effects

Medicines thought to be too harmful or toxic

Lack of belief in medicines

Concerns about safety of medicines/side effects

Influence of parents concerns about taking medicines

Fear of medicines adverse effects

Cognitive/memory related factors

Poor cognitive function, poor memory

Problems recalling regimen

Not remembering to refill prescription

Forgetfulness/failure to remember

Not emotionally ready for taking meds

Self-blame of condition

Changes to usual routine

Being away from home/travelling

Disruptions to daily routine/chaotic lifestyle

Not thinking there is a need for the medication

Communication barriers

Speaking different language to HCP

Poor health literacy

Poor or complex medication instructions

Communication problems with pharmacy

Drug and alcohol use

Alcohol use

Concomitant substance abuse

Healthcare provider related factors

Poor relationship with healthcare provider

Lack of trust in healthcare provider

Incompatibility of medicines taking with daily routine/lifestyle

Inconvenient or difficult to incorporate medicines taking/dosing time inconvenient

Lifestyle restriction from taking so many doses

Work, family or caregiving responsibilities

Too busy/distracted, lack of time

Falling asleep and missing meds time/sleeping through dose

Fasting for Ramadan

Perceived burden of extra planning

Too tired or unwell to take medicines

Interference with other activities

Skipping meals

Scheduling medicines administration into daily routine

Forgetting to bring medicines away with them/ being away from medicines at dose time

Knowledge related problems

Poor disease related knowledge

Lack of knowledge or understanding/ being misinformed

Not understanding the implications of the disease

Poor understanding of chronic nature of condition

Lack of understanding of medication benefit/ why prescribed

Lack of information about disease and its treatment

Poor education

Poor counselling

Not understanding how to reconcile newly prescribed drugs or how to get repeats

Not understanding new directions/ how to take medicine

Medicine administration problems

Problems taking meds at specific times

Problems taking more than one medicine at the same time

Taste and/or size of medicines

Difficult characteristics of medicines

Difficulty administering medicines – practical problems

Problems swallowing medicines or keeping them down

Problems accessing medicines

Patient confidence

Doubting ability to adhere/ low self-worth

Not emotionally ready for taking meds

Self-blame of condition

Patient preference for alternatives

Choosing traditional or herbal remedies instead of prescribed medication

Patient related factors

Feeling low/depressed/angry/stressed/hopeless/overwhelmed

Wanting to be free of taking medicines

Wanting to be ‘normal’

Wanting to maintain control

Not wanting to listen to authority figures

Being tired of taking pills

Treatment being a reminder of illness

Unwanted changes to body image/ effects on appearance

Feeling ready to die

Wanting to be with friends rather than take medicines

Lack of motivation

Low priority assigned to medicines taking

Refusal to take

Practical barriers

Long waiting times at the clinic or pharmacy

Running out of medicines

No time to obtain repeat prescription

Problems getting the meds form pharmacy e.g. medicine not available, problem getting a repeat, opening times

Transport difficulties for getting to clinics and appointments or pharmacy or being unable to get there

Logistical problems in accessing medicines

Financial constraints/ cost of medicines

No medical insurance/ insurance does not cover medicine

Homelessness/concurrent illness

Poor nutrition/ lack of access to food

No healthcare provider

Being away from medicine at time dose

Reading the labels on medicines

Losing medication

Regimen related factors

Regimen too complex/ confusing

Polypharmacy

Frequency of dosing

Heavy pill burden/ too many treatments

Changes to regimen or dose

Side effects of medicines

Side effects (real or anticipated)

Perceived side effects of treatment

ADRs

Social factors

Fear of stigma or discrimination

Fear of disclosure of illness

Lack of social support/ support from friends & family/ living alone

Negative publicity associated with medicines taking

Unwilling to take medicines in public

Social norms e.g. family rituals or social obligations

Concerns about image/perceptions of others/ bullying

Feeling embarrassed by taking medicines

Treatment related factors

Feeling better without treatment

Decreased QOL/feeling worse with treatment

Stopping medicines when feeling better

Stopping medicines as thought ineffective

 

Mapping to a theoretical framework

We mapped individual barriers from the literature review to one of 12 domains of the Theoretical Domains Framework. The mapping was undertaken by three experts in medication adherence and/or the Theoretical Domains Framework.

Focus groups with people prescribed medication

We invited people prescribed medication to help prevent heart disease to focus group discussions to get a better understating of the barriers to medication adherence. We presented them with the barriers identified from the literature search, organised into the domains of the Theoretical Domains Framework to stimulate discussion about the barriers to medication adherence.

Validation and clinical utility of the IMAB-Q

We tested how good the IMAB-Q is at accurately identifying a patient’s barriers to adherence and how easy it is to use in clinical practice by trialling it in community pharmacies with patients prescribed medication to help prevent heart disease. We did this by staff working in community pharmacies inviting patients to complete the IMAB-Q. A smaller sample of these patients were invited to complete the IMAB-Q twice with a two week interval to determine whether IMAB-Q when repeated provides consistent results. We will also asked pharmacists to use IMAB-Q in routine patient consultations (Medicines Use Reviews) to explore whether the IMAB-Q works in routine practice. Finally, we spoke to pharmacists who were involved in the study to find out their experiences of using the IMAB-Q. The results of this research can be found here.

Project Funding

The research to develop IMAB-Q was funded by the University of East Anglia and validation was funded by Pharmacy Research UK. The views expressed in this publication are those of the author(s) and not necessarily those of Pharmacy Research UK.

The full report of the IMAB-Q validation study can be found on the Pharmacy Research UK website here.

The Identification of Medication Adherence Barriers Questionnaire (IMAB-Q)

To download a copy of the questionnaire for your own purposes, please visit our questionnaire.

Project Principal Investigator
Dr Debi Bhattacharya
School of Pharmacy
University of East Anglia, Norwich Research Park
Norwich, Norfolk
NR4 7TJ

E-mail: d.bhattacharya@uea.ac.uk
Telephone: 01603 593391