hispanic medication adherence study - …hispanic medication adherence | 3 medications with over 70...

HISPANIC MEDICATION ADHERENCE STUDY

HISPANIC MEDICATION ADHERENCE | 1

TABLE OF CONTENTS

EXECUTIVE SUMMARY .......................................................................................................................................................................................... 2

INTRODUCTION ...................................................................................................................................................................................................... 4

STUDY OBJECTIVES .............................................................................................................................................................................................. 4

STUDY DESIGN AND METHODOLOGIES ............................................................................................................................................................. 5

PROVIDER KEY INFORMANT INTERVIEW RESULTS .......................................................................................................................................... 6

Insights from the Key Informants ......................................................................................................................................................................... 7

SURVEY RESULTS ................................................................................................................................................................................................ 10

When you don’t take your medication, what is the main reason you don’t take it? ....................................................................................... 17

Affordability .................................................................................................................................................................................................... 17

Ways to Improve Medication Adherence ....................................................................................................................................................... 17

What helps you remember your medication? ................................................................................................................................................ 18

What would help Hispanics take their medication? ....................................................................................................................................... 19

SUMMARY AND RECOMMENDATIONS ............................................................................................................................................................... 20

Some of the key findings we can draw from our research are the following ...................................................................................................... 20

Recommendations ......................................................................................................................................................................................... 21

Action items ................................................................................................................................................................................................... 21

ABOUT THE AUTHORS ......................................................................................................................................................................................... 22

About HolaDoctor ............................................................................................................................................................................................... 22

About EnvisionRx ............................................................................................................................................................................................... 22

About the Authors ............................................................................................................................................................................................... 22

CONTACTS ............................................................................................................................................................................................................ 23

EXHIBIT 1: HISPANIC MEDICATION ADHERENCE STUDY – COMPLETE RESPONSES TO ALL QUESTIONS .............................................. 24

Section A: Total Responses ............................................................................................................................................................................... 24

Section B: Demographics ................................................................................................................................................................................... 24

Section C: Medical History ................................................................................................................................................................................. 28

Section D: MMAS ............................................................................................................................................................................................... 30

Section E: Initial Prescription ............................................................................................................................................................................. 32

Section F: Fulfillment .......................................................................................................................................................................................... 35

Section G: Adherence ........................................................................................................................................................................................ 36

REFERENCES ....................................................................................................................................................................................................... 39


EXECUTIVE SUMMARY

Introduction: Hispanics are the largest and one of the fastest-growing minority groups in the United States. Hispanics have higher rates of certain medical conditions, e.g., diabetes, than non-Hispanic whites. For nearly all conditions, Hispanics have lower medication adherence than non-Hispanic whites. A limited number of interventions have been tested to increase medication compliance among Hispanics, but there is still very poor understanding of why Hispanics do not fill and/or adhere to their medication condition management protocols.

Objectives: The overall objective of the study was to increase our understanding of how this increasingly dominant demographic group use and adhere to medication protocols. Specific objectives were to: (1) Gain a better understanding of medication adherence among Hispanics, (2) Obtain a deeper understanding of the ways in which language determines how Hispanics are educated about and use prescribed medications, (3) Elicit recommendations from subject matter experts as well as Hispanics themselves on how to increase medication adherence and (4) Propose practical approaches to translating these insights into actionable interventions.

Design and Methodologies: The Hispanic Medication Study relied on three key sources of information: (1) A literature review using health and medical publications, (2) Key informant interviews with subject matter experts in the area of Hispanic health and (3) An online survey fielded to HolaDoctor’s database of over one million Hispanic health seekers residing in the U.S. and Puerto Rico.

Findings and Results from Literature Review and Key Informant Interviews: The findings from the literature review and key informant interviews offered a number of common insights and the barriers to good medication adherence. Among these were that: Hispanics tend to “wait” to bring themselves or their family members to see a doctor, often trying alternative/natural approaches first; low health literacy has a negative impact on health seeking and adherence; visits to doctors are avoided because employment is more likely to be hourly wage-based and if they aren’t working, they aren’t earning money; there is a low understanding of how prescribed medications work or what they are for and how they are to be taken, all leading to distrust they will work and lower adherence; there is a greater concern about side effects with prescribed medications among Hispanics compared to non-Hispanic whites; cost of copays can be a serious deterrent for lower income Hispanics. Regarding “what works” to increase adherence, tactics included: home visits by lay health workers; conducting “show and tell” sessions with Hispanic patients, where the patient or caretaker is made to handle each medication and tell the provider what each is, how it is used and what it is for; reminders, including text messaging, are showing promise.

Online Survey — Participants: We conducted an online survey with a total of 1,712 participants, 870 of whom were living in Puerto Rico and 842 of whom were in the United States. Fifty-one percent were between 35 and 54 years of age; 99 percent of survey respondents spoke Spanish at home. Three-quarters of the participants had some form of health insurance. Approximately 45 percent of the sample were taking three or more medications on a regular basis. High blood pressure, pain, high cholesterol, diabetes and acid reflux were the top conditions.

Online Survey — Findings and Results: Survey participants in the U.S. reported feeling more disconnected from their doctor than those in Puerto Rico due to cultural and language barriers. Doctors were by far the preferred source of information about


medications with over 70 percent of respondents preferring a doctor for information on medications in both the U.S. and Puerto Rico. Conversely, pharmacists were preferred by 24 percent of Puerto Rican respondents compared to just 13 percent of Hispanics in the U.S. Less than a third of Hispanics ranked high on a standardized medication adherence scale: two-thirds were either moderate or poor adherers. The top reasons for not taken ones medications were: I forget (40 percent), I felt better (20 percent), high cost (17 percent). Online information, email and text messaging were the top three things Hispanics felt would help them remember to take medications. The top five ways that people remembered to take their medications were: pain/feeling worse, having a routine, alarm or calendar reminders, putting the medications out so they can be seen and knowing they are important for health and feeling better. When asked what participants thought would help other Hispanics have higher medication adherence, the strongest recommendation, by far, was more education and information about the condition and the medication itself.

RECOMMENDATIONS AND ACTION ITEMS

Health care providers, health plans and others professionals designing interventions to increase medication adherence among Hispanics should consider the following:

• Hispanics have told us loud and clear, they need more and better understanding of their medical conditions and the medications they are being prescribed.

• While non-Hispanics tend to accept information from a wide range of sources, among Hispanics, the doctor is still king.

• Routines, alarms, calendars and simply putting medicines in a place that is easy to see are considered the most effective tactics for remembering to take one’s treatments.

• Hispanics are connected, mobile and technologically savvy. Online information, emails and text messages were all considered good ways to receive information and reminders.

Some things that health care educators and providers should do based on this study include:

• Creating information about standard medications and conditions that doctors can give to their patients in the exam rooms —this is a fast way for doctors to deliver information.

• Providing reminder tools through online and mobile technology to remind individuals to take their medications or take their medications with them.

• Pairing medication financial assistance programs with information regarding conditions so that patients can access information and understand how to use their medication.


INTRODUCTION

Hispanics are the largest and one of the fastest-growing minority groups in the United States1. By 2025, over 25 percent of the U.S. population is projected to be of Hispanic ethnicity. Hispanics have traditionally had the lowest rates of health insurance coverage of any demographic group2. An estimated eight in 10 uninsured Hispanics qualified for Medicaid, the Children’s Health Insurance Plan (CHIP) or lower costs on monthly premiums through the Health Insurance Marketplace. Since the passage of the Affordable Care Act, 4.2 million Hispanics (ages 18-64) have gained health insurance coverage, lowering the uninsured rate among Hispanics by 7.7 percent. If all states took advantage of new opportunities to expand Medicaid coverage under the Affordable Care Act, 95 percent of eligible uninsured Hispanics might qualify for Medicaid, CHIP or programs to help lower the cost of health insurance coverage in the Marketplace.3

Hispanics have higher rates of certain medical conditions, e.g., diabetes, than non-Hispanic whites4. For nearly all conditions, Hispanics have lower medication adherence than non-Hispanic whites5. Medication adherence among Hispanics is lower among Hispanics with heart disease6,7,8 and diabetes9, among other conditions. Hispanic Medicare recipients10,11 and those on psychotropic12 treatments also show significantly lower compliance with medication regimens than non-Hispanic whites.

Empirical data on the attitudes, beliefs and practices of uninsured Hispanics and the use of discount medication programs are severely lacking. A limited number of interventions have been tested to increase medication compliance among Hispanics13, but there is still very poor understanding of why Hispanics do not fill their prescriptions and/or adhere to their medication condition management protocols. This study seeks to increase our understanding of how this increasingly dominant demographic group uses and adheres to medication protocols.

STUDY OBJECTIVES

The objectives of this study were to:

• Gain a better understanding of medication adherence among Hispanics

• Obtain a deeper understanding of the ways in which language determines how Hispanics are educated about and use prescribed medications

• Elicit recommendations from subject matter experts as well as Hispanics themselves on how to increase medication adherence

• Propose practical approaches to translating these insights into actionable interventions


STUDY DESIGN AND METHODOLOGIES

The Hispanic Medication Study relied on three key sources of information:

• A literature review using health and medical publications

• Key informant interviews with subject matter experts in the area of Hispanic health

• An online survey fielded to HolaDoctor’s database of over one million Hispanic health seekers residing in the U.S. and Puerto Rico

In this report, we include the comprehensive findings from these three approaches. A version of the study results will be published as a shorter white paper as well as in an academic, peer-referenced journal article (forthcoming).

Online Study Population: HolaDoctor operates the largest network of Spanish-language health care websites on the Internet, with over 3.5 million unique Hispanic visitors monthly. Approximately one million of these unique Hispanic visitors reside in the U.S. or Puerto Rico.

HISPANICS ARE ONLINE AND MOBILEUntil recently, online surveys among Hispanics may have missed the lowest-income consumers, who did not have Internet access. Today, however, nearly 78 percent of Hispanics in the U.S. and Puerto Rico report using the Internet. As with the general market, a large and very fast-growing percentage of these consumers access the Internet through their smartphones or other web-enabled mobile devices. Of the more than millions of pages of Spanish-language health information HolaDoctor serves up each month, over 70 percent are accessed through consumers’ mobile devices, and 76 percent of Hispanic Internet users report accessing the Internet through a mobile device.14


Instrument Development: The survey instrument was based on best practices in the medication adherence field. The online questionnaire included demographic questions, the core set of questions from the MM4 questionnaire15 , culturally relevant questions particular to Hispanics and open-ended questions to elicit innovative strategies and tactics. A number of subject matter experts provided input on the survey question set. The final survey contained questions on demographics, health conditions, medication usage, attitudes, barriers and enablers to better medication compliance.

Recruitment: Hispanic consumers who had opted into to HolaDoctor’s online community were invited to participate in the survey through an email invitation. Participants who completed the survey were provided with a $10 Amazon gift card. The survey was fielded over two rounds, one during November 2014 and a second during January 2015.

Analysis: Frequencies tables were generated and stratified by residence (Puerto Rico vs. U.S. mainland). Differences were determined using chi-square at the p<0.05 significance level.

PROVIDER KEY INFORMANT INTERVIEW RESULTS

Three physicians who regularly care for Hispanic patients participated in the in-depth interviews:

• Dr. Eduardo Montana. Pediatric cardiologist and current chair of the Hispanic Health Coalition of Georgia

• Dr. Flavia Mercado. A pediatrician and former chair of the Hispanic Health Coalition of Georgia

• Dr. Ken Dominguez. A director of HIV/AIDS at the Centers for Disease Control and Prevention and chair of the CDC Hispanic employees working group

These subject matter experts/providers were interviewed about the barriers to medication adherence among Hispanics and, more importantly, what they have found works to increase adherence among this population. These key informants also provide input on the content of the survey instrument.


INSIGHTS FROM THE KEY INFORMANTS

The qualitative insights and examples provided by the key informant physicians have been grouped by topic below.

ATTITUDES TOWARD MEDICATIONS AND HESITANCY TO GO TO THE DOCTOR

• Hispanics wait to bring children to the doctor.

• Hispanics need to work and are often paid by the hour, so they are very reluctant to take time to go to the doctor.

• They know going to the doctor “opens up a whole process.” They are hesitant to “get into it all.”

LANGUAGE BARRIERS

• Even if the doctor speaks Spanish, they still often don’t understand what the doctor is saying. It is more than language; it is also “health literacy.”

PERSISTENCE

• Refills – they usually fill the first script, but then don’t refill it.

• Hispanics are more apt to share medicines.

CHRONIC CONDITIONS

• Chronic conditions are really tough because they need to keep track of so many medications for such a long period.

• They don’t understand that patients have to be on some medications for a long time.

• Asthma. They take curative medication, but they do not consistently take the maintenance meds.

• Case study: Diabetic teen on metformin. His whole family was diabetic. He didn’t take his meds because he didn’t feel bad. He didn’t understand why he should take it.

CONFLICT WITH SCHOOL

• Schools can make the process even more complicated. The doctor and family need to submit letters and have to be identified, so sometimes they just want to avoid the whole situation by not reporting asthma to the school.

• Asthma is the biggest chronic problem with children. We (doctors) start by teaching the parents, but “eventually we need to teach the children.”

• “We providers think that compliance is the most important, but they (the parents and kids) are dealing with lots of other things, like just getting to school.”


UNDERSTANDING MEDICATIONS

• Hispanics are very visual. They often just refer to the color of the pills — white pill, blue pill — but of course lots of pills are the same color, so that can create problems.

• Some doctors use a visual graph or the PDR.

• I had a patient whose child should be on ADHD meds, but the mom just didn’t want to have her child take it. She resisted and kept bringing in folk remedies.

• It’s very important that they understand WHY they are taking the medicines. This can be a real issue with Hispanic patients.

POOR UNDERSTANDING OF HOW TO USE MEDICATIONS

• Hispanics often have a very poor understanding of what medicines they have been prescribed and how to take them.

• It’s not uncommon that they put ear drops in the mouth.

• Case study of asthma patient: The child was admitted to the hospital, which gave the parents medications. The mother already had some medications from the doctor and then got additional medications from the emergency room. The mother was very confused, so she came to her provider. “I’m not sure which of all these medicines to give my son. I got one from doctor and one from the hospital,” she said. She brought three bags in to the doctor. She had medications from the doctor, hospital and emergency room. Some were the same medications, but some were generic and some brand name. Hispanics often get medications from Walmart that often don’t get recorded in the health plan records.

• What works best is to have them bring all of their medications in to the appointments and have the doctor explain what each one is for and how they are to be taken.

• In AIDS, the large number of pills is an issue. It works much better if pills can be combined so they take fewer pills fewer times per day.

• Elderly Hispanics: Need to use a large font and make the instructions clear.


SIDE EFFECTS

• Hispanics tend to be very afraid of side effects from Western medicines, but don’t like to complain. But also it is likely that they just don’t complain to me because I am the doctor.

• The key is to give them a heads up that there may be side effects.

COST

• Medicaid pays for some medications, health insurance others. The doctor has to be very careful to make sure the medications s/he is prescribing are affordable; otherwise, the patient won’t fill or refill them.

• Cost is the key. If a family is on Medicaid, they will be very compliant. If not, or if they don’t have another form of health insurance, they won’t.

WILLINGNESS TO TAKE MEDICATIONS

• Antibiotics: Hispanics are very willing to take antibiotics.

• “With kids and medicines, parents are really trying to do the right thing.”

• “I think Hispanics really don’t want to give medicines.” They feel like other things can help first, like traditional cures.

WHAT ELSE WORKS?

• Home visits by lay health workers: they can check to make sure that the meds are stored properly, refrigerated; and they can do educational follow-up.

• Show and tell: had parents show her how medications were administered.

• Provider recommendations: CDC has found that the strength of the provider recommendation is very important, especially among pregnant women.

• Reminders: text messaging and phone calls help.


SURVEY RESULTS

Study Population: A total of 1,712 Hispanic consumers completed the survey. Approximately half of the participants (n=870) were from Puerto Rico, while the rest were living in the United States (n=842). The states where they lived were the top five Hispanic states: California, Florida, Illinois, New York and Texas.

The majority of respondents were women (72 percent). The age distribution of the respondents is presented in the second graph at right. Nearly half of respondents were over 45 years old.

Language: The survey was presented in Spanish to a community that was initially sourced through Spanish-language health websites and a free prescription medication program. It is not surprising, then, that most spoke only Spanish at home, or a mix of Spanish and English. Less than one percent spoke only English at home. As expected, a significantly higher percentage of respondents living in Puerto Rico spoke only Spanish at home. In a separate question, 90 percent of participants indicated they prefer to receive health information in Spanish.

WHICH LANGUAGES DO YOU SPEAK AT HOME?*

United States Puerto Rico Total

English and Spanish equally 169 107 27622% 12% 17%

More Spanish than English 309 344 65340% 40% 40%

More English than Spanish 18 6 242% 1% 2%

Another language 5 0 51% 0% 0%

Only Spanish 260 405 66534% 47% 41%

Only English 4 2 61% <1% <1%

TOTAL 414 408 822

54%12%11%8%8%4%3%

ResidencePuerto Rico

Florida

Other

California

Texas

Illinois

New York

65+5%

5-6417%

45-5426% 35-44

25%

25-3422%

15-245%

Age Distribution

(n=1,639)


Health Insurance: Over three-quarters of the sample reported having health insurance. Insurance coverage was significantly higher for those living in Puerto Rico (93 percent) than those living in the mainland U.S. (56 percent). The percentage of respondents on Medicaid, 21 percent, matches national statistics, which show that 68 million of the 316 million people in the U.S. are covered by Medicaid at some point during the year16. For those with insurance, people living in the U.S. were more likely to have coverage through Affordable Care Act exchanges (known to Hispanics as “Obamacare”), while those living in Puerto Rico were more likely to be covered by private insurance through a private company.

INSURANCE TYPES FOR THOSE WITH COVERAGE

For those with health insurance, 83 percent indicated that they had prescription drug coverage.


Medicaid 79 161 24020% 22% 21%

Medicare 64 118 18216% 16% 16%

Insurance through an employer or spouse’s employer 145 258 40337% 35% 35%

Private insurance through Obamacare 69 43 11218% 6% 10%

Private insurance bought directly through a private company 37 167 2049% 23% 18%

None 335 58 39344% 7% 24%

TOTAL 762 862 1,624


MEDICAL CONDITIONS AND HISTORY

Nearly all of the respondents had one or more medical conditions and were taking one or more prescription medications. (See below.)

Number of Medical Conditions and Number of Medications Being Taken

Number of Medical Conditions0 12%1 18%2 17%3 17%4 11%5 7%

6 to 10 13%11+ 3%

Number of Medications Being Taken0 14%1 22%2 19%3 14%4 9%5 8%

6 to 10 12%11+ 3%

Number of Medications Prescribed0 13%1 19%2 16%3 16%4 10%5 8%

6 to 10 13%11+ 3%

86%(n=1,712)

have at least one medical condition and take at least one medication

The most prevalent medical conditions for which participants were taking medications were high blood pressure, pain, acid reflux and diabetes. Subjects living in Puerto Rico reported higher usage of medications for conditions.

Which Health Conditions Do You Take Medications For?

0%

10%

20%

30%

40%

50%

8%

18%

15%

20%23%22%

0%1%1%

19%22%

20%

31%

37%34%

19%

29%

23%

5% 5% 5%

9%

18%

14%

1% 1% 1%

30%

43%

37%

14%

20%

17%

8%

20%

14%

22%24%23%

Asthma High Cholesterol

COPD Diabetes Pain Acid Reflux Anemia Arthritis Birth Control High Blood Pressure

Mental Health/Depression

Hypo-/Hyperthyroidism

Other

n United States n Puerto Rico n Total


MEDICATION COMPLIANCE

The MMAS Score is a validated, standardized set of questions that measure medication adherence15. Notably, a low score indicates high adherence, while a high score indicates low adherence. About 22 percent of the sample had an MMAS score of 0, so were highly compliant. Approximately 32 percent of the sample had an MMAS score of 3 or 4, so were deemed to have low medication adherence.

MMAS Scores

0 1 2 3 4

31%

14%

22% 21%

25%23% 22%

24% 23%

17%

23%20%

9%

15%12%

0%

5%

10%

15%

20%

25%

30%

35%

The key questions that make up the MMAS are listed in the following table, along with the percentage of participants answering Yes or No to each one.


Have you ever forgotten to take medication for your condition?

No 330 248 57843% 29% 35%

Yes 441 618 1,05957% 71% 65%

TOTAL 771 866 1,637

Have you ever had problems remembering to take your medication?

No 503 482 98565% 56% 60%

Yes 265 381 64635% 44% 40%

TOTAL 768 863 1,631

When you feel better, do you sometimes stop taking your medications?

No 463 516 97960% 60% 60%

Yes 305 349 65440% 40% 40%

TOTAL 768 865 1,633

If you feel worse when taking your medication, do you stop taking it?

No 486 475 96163% 55% 59%

Yes 286 390 67637% 45% 41%

TOTAL 772 865 1,637



MEDICATION DISCOUNT CARD

About 40 percent of respondents use a medication discount card to help pay for medications, with a slightly higher usage among those living in Puerto Rico.

DO YOU USE A DISCOUNT MEDICATION PROGRAM TO HELP PAY FOR YOUR MEDICATION?*


No 414 510 92458% 64% 61%

Yes, I’m in a program sponsored by a pharmaceutical company 9 7 161% 1% 1%

Yes, I’m in a program sponsored by a pharmacy 44 22 666% 3% 4%

Yes, I receive a medication discount through the clinic I go to 40 5 456% 1% 3%

Yes, I use a medication discount card 169 221 39024% 28% 26%

Yes, I’m in a different program that decreases my medication costs 38 33 715% 4% 5%

TOTAL 714 798 1,512

OF THOSE WHO USE MEDICATION DISCOUNT CARDS, ARE THEY UNIVISION CARDS OR OTHER CARDS?


Other40 26 66

19% 10% 14%

Univision169 235 40481% 90% 86%

TOTAL 209 261 470

The high percentage of people with medication discount cards who responded that they have a Univision card is due to the fact that one of the sources of the sample population was people who had signed up for a medication discount card administered by Univision, EnvisionRx and HolaDoctor.


INTERACTING WITH DOCTORS AND HEALTH PROFESSIONALS ABOUT PRESCRIPTION MEDICATIONS: THE ROLE OF LANGUAGE

When asked “Do you trust your doctor for information about prescription medications?,” 83 percent indicated that they always or usually trust their doctor.

When asked “Have you ever felt disconnected from your doctor because of your culture?,” 23 percent of those living in the U.S. said that they had, compared to only eight percent of those living in Puerto Rico. The fact that nearly all doctors in Puerto Rico are from the island and speak Spanish, whereas in the U.S. there are few Spanish-speaking, culturally competent physicians, likely explains this significant difference.

HAVE YOU EVER FELT DISCONNECTED FROM YOUR DOCTOR BECAUSE OF YOUR CULTURE?


No569 755 132477% 92% 85%

Yes170 63 23323% 8% 15%

TOTAL 739 818 1,557

Interestingly, when participants were asked “How often do you have difficulty communicating with your doctor?,” the rates were similar among respondents in the U.S. and Puerto Rico.

HOW OFTEN DO YOU HAVE DIFFICULTY COMMUNICATING WITH YOUR DOCTOR?


Usually48 35 836% 4% 5%

Sometimes149 143 29220% 17% 18%

Once in a while143 137 28019% 16% 17%

Never/Rarely425 536 96156% 63% 60%

TOTAL 765 851 1,616


The preferred source of information about medications was overwhelmingly a doctor, but pharmacists were much more highly regarded in Puerto Rico than in the U.S.

Preferred Source of Information about Medications(n=1,712)

n United States n Puerto Rico

Doctor Pharmacist Nurse

78%72%

13%

24%

2% 1% 2% 1%5% 3% 1% 1%

Family Member Health Promoter Friend0%

10%

20%

30%

40%

50%

60%

70%

80%

ADHERENCE

Overwhelmingly, the most common reason participants did not take their medication was because they forgot.


When You Don’t Take Your Medication, What Is the Main Reason You Don’t Take It?n United States n Puerto Rico n Total

0%

10%

20%

30%

40%

50%

Financial reasons/

too expensive

It’s too difficult to go to the pharmacy

I feel better

I feel worse

Need to get a refill

I don’t understand why I have to take it

I forget I don’t need it

anymore

Other N/A (I always

take them)

AFFORDABILITY

Nearly 40 percent of the survey participants felt that their medications were either “unaffordable” (28 percent) or “very unaffordable” (11 percent).

WAYS TO IMPROVE MEDICATION ADHERENCE

The survey included a series of questions about things Hispanics felt would help them to remember to take medications. Those answering “yes” to closed-ended questions about specific tactics are presented in the graphic below.

WAYS TO REMEMBER TO TAKE MEDICATION: PERCENT ANSWERING “YES”(n=1,712)

ONLINE INFORMATION

United States 87%Puerto Rico 90%

EMAIL REMINDERS


TEXT REMINDERS


@


We also asked the open-ended question “What helps you remember your medication?” The results were grouped and are presented in the following table. Besides feeling pain or discomfort, the three most common responses referenced the importance of routine, alarms/calendars and having the pills in a place where they can easily be seen.

WHAT HELPS YOU REMEMBER YOUR MEDICATION?

Number of MentionsPain and/or feeling worse 110Have a certain routine 108Alarm/calendar reminder 90Seeing the medications/putting them where they can be seen 74Knowing it’s important for my health/wanting to feel better 71Family/individual reminds me 38Pillbox 27Other reminders (calls, emails, written, texts, phone apps) 26Other 12Better financial access 2

REPRESENTATIVE QUOTATIONS FROM INDIVIDUALS WHEN ASKED WHAT HELPS THEM REMEMBER THEIR MEDICATION• I have a routine, and I also write it on a note on my fridge to be able to remember.

• Knowing that some medications are necessary to get better from whatever illness one is suffering from and avoid something more serious or causing the illness to get worse or become fatal.

• When I’m feeling well, I always remember.

• A family member reminds me, and I note it on my cell phone calendar.

• My son is my reason for staying healthy. He is only five years old, and I am a widow, so it’s just us.

• I am very forgetful when it comes to taking medications, but if someone reminds me, it helps me to remember.


The final question asked the participants was “What would help Hispanics take their medication?” In other research, we have found that this question is revealing in that it takes the focus away from individual respondents and forces them to think about ways that might work for others like them. The overwhelming majority of responses indicated that Hispanics feel that better education and information about both the medical condition and the medications would be helpful in improving medication adherence. Alarms, reminders and routines were also mentioned, as they were in the previous question. Some suggested that better financial assistance and access (e.g., lower prices) would be helpful. Notably, only a small number of people felt that more information in Spanish or Spanish-speaking doctors was key to better adherence. This may be because most medication instructions are now available in Spanish.

WHAT WOULD HELP HISPANICS TAKE THEIR MEDICATION?

Number of MentionsMore education/information regarding the condition and medication 168Alarms/reminders through alarms or email 71Better access/financial help to buy medications 63Establishing a routine 57Text messaging/applications 37Reminders from family members 28Other 20Spanish-language materials/information 7Other written/television reminders 6Better doctors/doctors who speak Spanish 5Pillbox 4

REPRESENTATIVE QUOTATIONS WHEN ASKED “WHAT WOULD HELP HISPANICS TAKE THEIR MEDICATION?”• Being better informed and knowing the benefits associated with taking them,

without ignoring the risks associated with taking them.

• Knowing that in order to make progress as a family, they need to be healthy.

• Educating about the illness and learning more about it.

• First being able to get it, then individually coming up with their own system that helps them remember to take it.

• Having better access to information in a clear, complete and simple manner, either through a doctor or pharmacist who is trusted.

• Having access to good medical treatment and advice in their own language.


SUMMARY AND RECOMMENDATIONS

This study sought to better understand medication usage and adherence among the fast-growing and increasingly important Hispanic population. The large survey population was representative of Hispanics living in the U.S. or Puerto Rico and enabled us to compare and contrast whether there were differences between these two groups.

SOME OF THE KEY FINDINGS WE CAN DRAW FROM OUR RESEARCH ARE THE FOLLOWING

• Among this study population of mostly 25- to 55-year-old Hispanic females, many suffer from a number of medical conditions and are taking multiple medications for these maladies.

• Like non-Hispanics, understanding these conditions and the prescribed treatments can be difficult. Most do not take their medications at times.

• Hispanics trust their doctor most for information about their medications. In Puerto Rico, pharmacists are highly trusted. Notably, nurses were not well trusted for medication information.

• Less than a third of Hispanics ranked high on a standardized medication adherence scale: two-thirds were either moderate or poor adherers.

• Establishing a routine, setting up alarms and reminders and placing the medications in a place that is easy to see are key tactics to remember treatments.

• Online information, email reminders and text messaging were all perceived as valuable ways to increase adherence.

• Through an open-ended question set, Hispanics suggested that “better information about the medical conditions as well as the medications themselves” was sorely needed and that helping people understand these better could significantly increase medication adherence.


RECOMMENDATIONS

Health care providers, health plans and other professionals designing interventions to increase medication adherence among Hispanics should consider the following:

• Hispanics have told us loud and clear that they need more and better understanding of their medical conditions and the medications they are being prescribed.

• While non-Hispanics tend to accept information from a wide range of sources, among Hispanics, the doctor is still king.

• Routines, alarms, calendars and simply putting medicines in a place that is easy to see are considered the most effective tactics for remembering to take one’s medications.

• Hispanics are connected, mobile and technologically savvy. Online information, emails and text messages were all considered good ways to receive information and reminders.

ACTION ITEMS

• Create information about standard medications and conditions that doctors can give to their patients in the exam rooms — this is a fast way for doctors to deliver information.

• Provide reminder tools through online and mobile technology to remind individuals to take their medications or take their medications with them.

• Pair medication financial assistance programs with information regarding conditions so that patients can access information and understand how to use their medication.


ABOUT THE AUTHORS

ABOUT HOLADOCTOR

HolaDoctor Inc. (www.holadoctor.net) is the leading Hispanic health marketing company in the U.S. HolaDoctor owns and operates the most popular Spanish-language health care website online (www.holadoctor.com) and is the exclusive health partner to Univision Interactive. The company provides strategic consulting, marketing solutions and culturally relevant programs to health plans, providers, governmental agencies and other health care entities. HolaDoctor has offices in Atlanta, Miami and Mexico City.

ABOUT ENVISIONRX

EnvisionRxOptions is a health care and pharmacy benefit management (PBM) company headquartered in Twinsburg, Ohio. We have over 1,500 employees supporting a rapidly growing membership base of over 23 million members, creating savings for them as well as thousands of plan sponsors. Rite Aid’s acquisition of Envision in 2015 brings together two national health care companies that give consumers more pharmacy options and give plan sponsors improved manufacturer relationships and analytic capabilities.

ABOUT THE AUTHORS

Dirk G. Schroeder, ScD, MPH: Dr. Schroeder is the executive VP and Chief Health Officer at HolaDoctor Inc. He is also an adjunct associate professor of global health at Emory University. He is a recognized expert in Hispanic health issues, including ways to increase access and address health disparities. Dr. Schroeder has lived and worked throughout Latin America as well as Southeast Asia. He has doctoral and master’s degrees in international health from Johns Hopkins University and a post-doc from Cornell. He completed his undergraduate work, with honors and distinction, at Stanford University.

Meryam Alaoui: As general manager for EnvisionSavings, the direct-to-consumer line of business for EnvisionRxOptions, a national, fully integrated health care company, Ms. Alaoui oversees all prescription discount programs and copay buy-down offerings administered nationally by EnvisionRx. In this capacity, she works with public- and private-sector clients, including states, municipalities, nonprofit organizations and employers, to deliver valuable services to more than 10 million lives. Prior to joining Envision in 2009, Ms. Alaoui held executive roles with American Express in Finance, Operations, Tax, Treasury and Merchant Services. Before American Express, she worked for the National Council on Compensation Insurance (NCCI) overseeing the Assigned Risk investment portfolio.

Brianna Keefe-Oates, MPH: Ms. Keefe-Oates serves as part of the strategic consulting branch of HolaDoctor. She has most recently worked on educational outreach programs focused on educating individuals about the Affordable Care Act. Ms. Keefe-Oates also has experience implementing health prevention projects with Hispanics in the Southeast U.S. and nationally. Ms. Keefe-Oates has worked on research and outreach projects in Paraguay and the Dominican Republic, where she spent three years as a Peace Corps volunteer. Ms. Keefe-Oates received a bachelor’s degree in Latin American studies from Macalester College and a master of public health degree from Emory University.


CONTACTS

Dr. Dirk G. SchroederPrincipal InvestigatorEVP & Chief Health OfficerHolaDoctor, Inc.900 Old Roswell Lakes Parkway, Suite 230Roswell, Georgia [email protected](678) 749-6772


EXHIBIT 1: HISPANIC MEDICATION ADHERENCE STUDY – COMPLETE RESPONSES TO ALL QUESTIONS

SECTION A: TOTAL RESPONSES

United States 842 49%Puerto Rico 870 51%Grand Total 1,712 100%

SECTION B: DEMOGRAPHICS

SEX*


Female516 649 116568% 75% 72%

Male244 212 45632% 25% 28%

TOTAL 760 861 1,621


AGE


15-2442 39 815% 4% 5%

25-34197 171 36826% 20% 22%

35-44222 191 41329% 22% 25%

45-54157 270 42720% 31% 26%

55-64118 156 27415% 18% 17%

65+34 42 764% 5% 5%

TOTAL 770 869 1,639

STATE/TERRITORY RESIDENCE

54%

12%

11%

8%

8%

4%

3%

Puerto Rico

Florida

Other

California

Texas

Illinois

New York


WHICH LANGUAGES DO YOU SPEAK AT HOME?*


English and Spanish equally169 107 27622% 12% 17%

More Spanish than English309 344 65340% 40% 40%

More English than Spanish18 6 242% 1% 2%

Another language5 0 5

1% 0% 0%

Only Spanish260 405 66534% 47% 41%

Only English4 2 6

1% <1% <1%TOTAL 414 408 822

IN WHICH LANGUAGE DO YOU PREFER TO RECEIVE INFORMATION ABOUT YOUR MEDICATIONS?


Spanish675 788 146389% 91% 90%

English84 74 158

11% 9% 10%TOTAL 759 862 1,621

DO YOU CURRENTLY HAVE INSURANCE?**


No335 58 39344% 7% 24%

Yes427 862 123156% 93% 76%

TOTAL 762 862 1,624


FOR THOSE WHO HAVE INSURANCE, WHAT KIND OF INSURANCE?*


Medicaid79 161 240

20% 22% 21%

Medicare64 118 182

16% 16% 16%

Insurance through an employer or spouse’s employer145 258 40337% 35% 35%

Private insurance through Obamacare69 43 112

18% 6% 10%

Private insurance bought directly through a private company37 167 2049% 23% 18%

TOTAL 394 747 1141

DOES YOUR INSURANCE COVER YOUR PRESCRIPTION MEDICATIONS?


No67 139 206

16% 18% 17%

Yes346 629 97584% 82% 83%

TOTAL 413 768 1181


SECTION C: MEDICAL HISTORY

HOW MANY MEDICAL CONDITIONS DO YOU HAVE?

0: 12% 1: 18% 2: 17% 3: 17% 4: 11% 5: 7% 6-10: 13% 11+: 3%

HOW MANY MEDICATIONS ARE YOU CURRENTLY PRESCRIBED?


11+15 38 532% 4% 3%

Six to 1076 146 2229% 17% 13%

Five40 95 1355% 11% 8%

Four66 99 1658% 11% 10%

Three128 143 27115% 16% 16%

Two169 143 27115% 16% 16%

One193 130 32323% 15% 19%

Zero155 76 23118% 9% 13%

TOTAL 842 879 1,712


HOW MANY MEDICATIONS ARE YOU CURRENTLY TAKING?


11+9 33 42

1% 4% 2.5%

Six to 1071 134 2058% 15% 12%

Five36 94 1304% 11% 8%

Four63 89 1527% 10% 9%

Three108 132 24013% 15% 14%

Two181 149 33022% 17% 19%

One207 173 38025% 20% 22%

Zero167 66 23320% 8% 14%

TOTAL 842 870 1,712

For Which Conditions Are You Currently Prescribed Medication? (Respondents were able to select more than one)


0%

10%

20%

30%

40%

50%

8%

18%

15%

20%23%22%

0%1%1%

19%22%

20%

31%

37%34%

19%

29%

23%

5% 5% 5%

9%

18%

14%

1% 1% 1%

30%

43%

37%

14%

20%

17%

8%

20%

14%

22%24%23%

Asthma High Cholesterol

COPD Diabetes Pain Acid Reflux Anemia Arthritis Birth Control High Blood Pressure

Mental Health/Depression

Hypo-/Hyperthyroidism

Other


SECTION D: MMAS

MMAS Overall Average: 1.8 (1-2=Moderately adherent) MMAS PR: 2.0 MMAS Other: 1.5

MMAS Scoresn United States n Puerto Rico n Total

0 1 2 3 4

31%

14%

22% 21%

25%23% 22%

24% 23%

17%

23%20%

9%

15%12%

0%

5%

10%

15%

20%

25%

30%

35%

HAVE YOU EVER FORGOTTEN TO TAKE MEDICATION FOR YOUR CONDITION?**


No330 248 57843% 29% 35%

Yes441 618 105957% 71% 65%

TOTAL 771 866 1,637

HAVE YOU EVER HAD PROBLEMS REMEMBERING TO TAKE YOUR MEDICATION?**


No503 482 98565% 56% 60%

Yes265 381 64635% 44% 40%

TOTAL 768 863 1,631


WHEN YOU FEEL BETTER DO YOU SOMETIMES STOP TAKING YOUR MEDICATIONS?


No463 516 97960% 60% 60%

Yes305 349 65440% 40% 40%

TOTAL 768 865 1,633

IF YOU FEEL WORSE WHEN TAKING YOUR MEDICATION, DO YOU STOP TAKING IT?**


No486 475 96163% 55% 59%

Yes286 390 67637% 45% 41%

TOTAL 772 865 1,637


SECTION E: INITIAL PRESCRIPTION

DO YOU USE A DISCOUNT MEDICATION PROGRAM TO HELP PAY FOR YOUR MEDICATION?*


No414 510 92458% 64% 61%

Yes, I’m in a program sponsored by a pharmaceutical company9 7 16

1% 1% 1%

Yes, I’m in a program sponsored by a pharmacy44 22 666% 3% 4%

Yes, I receive a medication discount through the clinic I go to40 5 456% 1% 3%

Yes, I use a medication discount card169 221 39024% 28% 26%

Yes, I’m in a different program that decreases my medication costs38 33 715% 4% 5%

TOTAL 714 798 1,512

OF THOSE WHO USE MEDICATION DISCOUNT CARDS, ARE THEY UNIVISION CARDS OR OTHER CARDS?


Other40 26 66

19% 10% 14%

Univision169 235 40481% 90% 86%

TOTAL 209 261 470


HOW FREQUENTLY DO YOU TRUST THE INFORMATION THAT YOUR DOCTOR GIVES YOU REGARDING YOUR HEALTH AND MEDICATION?*


Always295 337 63240% 42% 41%

Usually289 357 64640% 44% 42%

Sometimes65 69 1349% 9% 9%

Once in a while54 34 887% 4% 6%

Never/rarely27 12 394% 2% 3%

TOTAL 730 809 1,539

HAVE YOU EVER FELT DISCONNECTED FROM YOUR DOCTOR BECAUSE OF YOUR CULTURE?**


No569 755 132477% 92% 85%

Yes170 63 23323% 8% 15%

TOTAL 739 818 1,557


HOW OFTEN DO YOU HAVE DIFFICULTY COMMUNICATING WITH YOUR DOCTOR?


Usually48 35 836% 4% 5%

Sometimes149 143 29220% 17% 18%

Once in a while143 137 28019% 16% 17%

Never/rarely425 536 96156% 63% 60%

TOTAL 765 851 1616

WHO WOULD YOU PREFER TO GIVE YOU INFORMATION ABOUT HOW TO TAKE YOUR MEDICATION?*


Friend4 1 5

<1% <1% <1%

Doctor611 620 123178% 72% 75%

Nurse12 4 162% <1% 1%

Family member16 12 282% 1% 2%

Pharmacist102 206 30813% 24% 19%

Health promoter37 22 595% 3% 4%

TOTAL 782 865 1647


SECTION F: FULFILLMENT

HOW OFTEN DO YOU HAVE DIFFICULTY COMMUNICATING WITH YOUR PHARMACIST?*


Always30 15 454% 2% 3%

Usually29 25 544% 3% 3%

Sometimes112 100 21214% 12% 13%

Once in a while120 106 22615% 12% 14%

Never/rarely502 614 111663% 71% 68%

TOTAL 793 860 1653

HOW OFTEN DO YOU HAVE DIFFICULTY REFILLING YOUR PRESCRIPTION?


Always23 6 293% 1% 2%

Usually30 21 514% 2% 3%

Sometimes188 147 26515% 17% 16%

Once in a while146 161 30718% 19% 19%

Never/rarely475 524 99960% 61% 61%

TOTAL 792 859 1651


SECTION G: ADHERENCE

When You Don’t Take Your Medication, What Is the Main Reason You Don’t Take It?

0%

10%

20%

30%

40%

50%

Financial reasons/

too expensive

It’s too difficult to go to the pharmacy

I feel better

I feel worse

Need to get a refill

I don’t understand why I have to take it

I forget I don’t need it

anymore

Other N/A (I always

take them)

HOW AFFORDABLE ARE YOUR PERSONAL MEDICATIONS?*


Very affordable171 119 29022% 14% 18%

Affordable323 411 73441% 48% 44%

Unaffordable206 252 45826% 29% 28%

Very unaffordable95 82 177

12% 10% 11%TOTAL 795 864 1659


IF YOU READ ADDITIONAL INFORMATION ONLINE ABOUT YOUR CONDITION AND MEDICATION, WOULD IT HELP YOU TAKE YOUR MEDICATION?


No103 86 18913% 10% 11%

Yes691 777 146887% 90% 89%

TOTAL 794 863 1657

WOULD EMAIL REMINDERS HELP YOU TAKE YOUR MEDICATION?


No351 369 72044% 43% 44%

Yes442 492 93456% 57% 56%

TOTAL 793 861 1654

WOULD TEXT REMINDERS HELP YOU TAKE YOUR MEDICATION?


No157 183 34042% 40% 41%

Yes221 271 49259% 60% 59%

TOTAL 378 454 832

WHAT USUALLY HELPS YOU REMEMBER TO TAKE YOUR MEDICATION?

Number of MentionsPain and/or feeling worse 110Have a certain routine 108Alarm/calendar reminder 90Seeing the medications/putting them where they can be seen 74Knowing it’s important for my health/wanting to feel better 71Family/individual reminds me 38Pillbox 27Other reminders (calls, emails, written, texts, phone apps) 26Other 12Better financial access 2


WHAT WOULD HELP HISPANICS TAKE THEIR MEDICATION?

Number of MentionsMore education/information regarding the condition and medication 168Alarms/reminders through alarms or email 71Better access/financial help to buy medications 63Establishing a routine 57Text messaging/applications 37Family or other person helping them to remember 28Other 20Spanish-language materials/information 7Other written/television reminders 6Better doctors/doctors who speak Spanish 5Pillbox 4


REFERENCES

1 U.S. Census Community Survey, 2013.

2 U.S. Census Community Survey, 2013.

3 http://www.hhs.gov/healthcare/facts-and-features/fact-sheets/aca-working-latino-community/index.html.

4 HHS Office of Minority Health, 2013.

5 Colby JA, Wang F, Chhabra J, Perez-Escamilla R. Predictors of medication adherence in an urban Latino community with healthcare disparities. J Immigr Minor Health. 2012 Aug;14(4):589-95.

6 Zhang Y, Baik SH. Race/ethnicity, disability and medication adherence among Medicare beneficiaries with heart failure. J Gen Intern Med. 2014 Apr;29(4):602-7.

7 Zhang Y, Baik SH, Chang CC, Kaplan CM, Lave JR. Disability, race/ethnicity and medication adherence among Medicare myocardial infarction survivors. Am Heart J. 2012 Sep;164(3):425-433.e4.

8 Lauffenburger JC, Robinson JG, Oramasionwu C, Fang G. Racial/ethnic and gender gaps in the use of and adherence to evidence-based preventive therapies among elderly Medicare Part D beneficiaries after acute myocardial infarction. Circulation. 2014 Feb 18;129(7):754-63.

9 Parada H Jr, Horton LA, Cherrington A, Ibarra L, Ayala GX. Correlates of medication nonadherence among Latinos with type 2 diabetes. Diabetes Educ. 2012 Jul-Aug;38(4):552-61.

10 Gaskin DJ, Briesacher BA, Limcangco R, Brigantti BL. Exploring racial and ethnic disparities in prescription drug spending and use among Medicare beneficiaries. Am J Geriatr Pharmacother. 2006 Jun;4(2):96-111.

11 Frankenfield DL, Wei II, Anderson KK, Howell BL, Waldo D, Sekscenski E. Prescription medication cost-related non-adherence among Medicare CAHPS respondents: disparity by Hispanic ethnicity. J Health Care Poor Underserved. 2010 May;21(2):518-43.

12 Lanouette NM, Folsom DP, Sciolla A, Jeste DV. Psychotropic medication nonadherence among United States Latinos: a comprehensive literature review. Psychiatr Serv. 2009 Feb;60(2):157-74. doi: 10.1176/appi.ps.60.2.157. Review.

13 Hu D, Juarez DT, Yeboah M, Castillo TP. Interventions to increase medication adherence in African-American and Latino populations: a literature review. Hawaii J Med Public Health. 2014 Jan;73(1):11-8.

14 Lopez, H, Gonzalez-Barrera, A, Patten, E. “Internet Use,” Closing the Digital Divide: Latinos and Technology Adoption. Pew Research Center, Hispanic Trends. 7 March, 2013.

15 Pedersini, R, Isherwood, G, Vietri, J. “Harmonizing measurement of adherence across the 4 item and 8 item Moriskey Medication Adherence Scale using cross-sectional data from patients treated for irritable bowel syndrome.” Kantar Health, Poster presented at the ISPOR 18th Annual European Congress, Dublin, Ireland. 2-6 November, 2013.

16 HHS and U.S. Census, 2015.

*=Could be a significant difference between Puerto Rican respondents and all other respondents, but difficult to determine **=Significant difference

hispanic medication adherence study - …hispanic medication adherence | 3 medications with over 70...

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