using self-regulation theory to examine patient goals, barriers, and facilitators for taking...

Using Self-Regulation Theory to ExaminePatient Goals, Barriers, and Facilitatorsfor Taking MedicationSuzan N. Kucukarslan, Sheena Thomas, Abraham Bazzi and Deborah Virant-Young

College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA

Abstract Background: Self-regulation theory predicts that patient behavior is de-

termined by the patient’s assessment of his/her condition (illness presenta-

tion) and related health goals. Patients will adapt their behavior to achieve

those goals. However, there are multiple levels of goals. In such cases, those

lower-level goals (health goals) that are strongly correlated with higher-level

goals (i.e. quality of life [QOL]) are more likely to drive patient behavior.

Medication non-compliance is a health behavior that challenges healthcare

practitioners. Thus, the primary aim of this paper is to explore the relation-

ship between the lower-level goals for taking medication with higher-level

goals. This paper also identifies patient-perceived barriers and facilitators

toward achieving goals as they may relate to patients’ illness representation.

Objectives: To identify lower- and higher-level goals associated with medi-

cation use for chronic conditions. To determine if there is a relationship

between higher-level (global) goals and lower-level (health-related) goals. To

identify patient-perceived facilitators and barriers to achieving those goals.

Methods: This was a prospective, observational study using a mailed survey.

The setting was a US Midwestern state-wide survey. Participants were pa-

tients living in the community with hypertension, heart disease, diabetes

mellitus, or arthritis, and taking prescription medication for any one of those

conditions. The main outcome measures were lower- and higher-level goals

related to medication use. The survey asked the participants if they had

achieved their goals and to identify factors that may pose as barriers or fa-

cilitators to achieving them. Pearson correlation was used to test the re-

lationship between the lower- and higher-level goals at p < 0.05.Results: Responses from 292 qualifying patients were obtained. A significant

relationship between lower- and higher-level goals existed (p = 0.03). Pre-venting future health problems was the most important lower-level goal for

almost half of the respondents. Approximately 43% of the respondents said

‘improving or maintaining quality of life’ was their most important higher-

level goal. Elderly respondents (65 years or older) said that being able to carry

out daily activities on their own was their most important higher-level goal.

ORIGINAL RESEARCH ARTICLEPatient 2009; 2 (4): 211-220

1178-1653/09/0004-0211/$49.95/0

ª 2009 Adis Data Information BV. All rights reserved.

To achieve this goal, they identified ‘preventing future health problems’ as

the associated lower-level goal. One-third of the respondents stated that they

had not yet achieved their medication-related goals. Patients identified good

communication with their physicians (35%), the effectiveness of the drug

product (32%), and their ability to monitor their condition (20%) as im-

portant factors toward helping them achieve their goals. Medication costs

(30%), drug adverse effects (25%), and the lack of drug effectiveness (22%)

were factors that patients identified as barriers to achieving their goals.

Conclusion: There is a significant and positive relationship between the lower-

and higher-level goals. Healthcare providers can work with their patients to

achieve their goals. Both good communication with the prescriber and the

effectiveness of the drug product were identified as the most important fa-

cilitator by one-third of the respondents. Future research should study if

relating the impact of good symptom control or the reduction of future health

risks to QOL or longevity, as deemed relevant by the patient, influences

medication adherence behavior.

Background

There are many individuals faced with mana-ging multiple chronic conditions. Approximatelyone in five persons between the ages of 55 and64 years old has three or more chronic conditions.The incidence of chronic conditions increases withage, with one in three elderly (‡65 years) havingthree or more chronic conditions.[1] Patients withchronic conditions face many healthcare deci-sions. Some may strive to control their conditionwhile others may choose to ignore it. They maychoose to take medication and/or to make life-style changes. Although taking medication is oneoption for many patients to achieve their health-related goals, it is estimated that 30–50% of pa-tients may choose not to take their medication.[2]

These decisions can be influenced by patients’goals and their ability to achieve them. The pur-pose of this study is to identify goals for takingmedication from the patient perspective and toidentify factors that may impact patients’ abilityto achieve those goals.

Chewning and Sleath[3] proposed an increasedrole of the patient in the medical decision-makingprocess. They suggested that the patient is themost under-utilized resource in medical care. Apatient-centered model of care requires the health-

care providers to communicate effectively withthe patient when identifying goals and choosingtreatment plans. Patients and healthcare provi-ders should communicate regularly to monitorhow patients are progressing. This empowers thepatient to manage their condition and to achievetheir health-related goals.

Chronic care models have demonstrated thathealthcare providers who regularly communicatewith patients improve patients’ clinical outcomessuch as a targeted blood pressure or cholesterollevel.[4] Patients with questions or concerns aboutmedication or self-monitoring of their conditionare able to work with healthcare providers toaddress their questions or concerns and thusachieve their clinical goals. Interestingly, Lorig andcolleagues[4] demonstrated that a non-disease-specific patient empowerment program can signif-icantly improve patient well-being (psychologicaland symptom based) and reduce hospitalizations.Patients can self-manage to achieve a betterquality of life (QOL) and reduce the use of expen-sive healthcare resources when given educationand support.

The theory of self-regulation can be used todescribe patient self-management. Patients beginby assessing their current health status and deter-mining its personal relevance, influenced by their

212 Kucukarslan et al.

ª 2009 Adis Data Information BV. All rights reserved. Patient 2009; 2 (4)

beliefs, expectations, or goals. Lazarus[5] foundthat individuals perceive their status and gothrough an appraisal process of comparing theircurrent state with their goals. A significant in-congruence between their current state and theirgoals results in behavior that addresses that in-congruence (coping behavior). In health psy-chology, the appraisal process described byLazarus[5] is described as an individual’s illnessrepresentation.

An individual’s illness representation has fivecomponents: identity, time, cause, consequence,and control. An individual’s appraisal of theirillness or health state involves understanding itssymptoms or future health risks (identity), its time-line or duration (time), its contributing factors(cause), resulting outcomes (consequences), andthe patient’s ability tomanage it (control). Illness re-presentation is a primary component of Leventhal’scommon-sense model of self-regulation.[6] Anindividual’s illness representation results in goalsthat drive the behavior to achieve them. The re-sulting outcomes are compared with their desiredgoals. Discrepancies between desired goals and out-comes are re-appraised by patients.[6] Health be-havior is determined by this self-regulation process.

Goal congruence can be evaluated by func-tional or by hierarchical mechanisms.[7] The func-tional mechanism evaluates a perceived outcome(blood pressure) of a behavior with the desiredgoal (targeted blood pressure). A discrepancybetween these two values would be evaluated bythe patient and its significance would impact thepatient’s illness representation and thus futurebehavior. Individuals have specific goals relatedto their illness representation and the resultingoutcomes are compared with those goals.

The hierarchical goal mechanism recognizesthat goals can be expressed at different levels ofabstraction. Levels of abstraction can be differ-entiated as lower-level goals that are related toperceptual sensations or higher-level goals thatare more abstract in nature. For example, in-dividuals can identify their illness by evaluatingtheir symptoms related to their illness or byevaluating how they are able to perform at work.Goals that involve illness symptoms are goalsdefined at a lower level of abstraction, while those

such as work productivity are at a higher level ofabstraction. The relationship between lower- andhigher-level goals can impact patient behavior. Ifpatients have multiple lower-level goals (i.e. con-trolling blood pressure, reducing adverse effectsof medication), they will behave to achieve thegoal more strongly related to an importanthigher-level goal (i.e. work productivity).[7] Thestrength of the relationship between the lower-and higher-level goal is theorized to impact pa-tient decision making.

Patients take their medication to controlsymptoms and to achieve targeted clinical out-comes, while minimizing any risks of adverse drugevents.[8] These endpoints are immediate goals ofusing medication. Patients take on other roles inour society such as parent, spouse, employee, andmany others. Therefore, they have higher-levelgoals that affect their everyday life. It is impor-tant to recognize these higher-level goals and tounderstand how they may affect patients’ deci-sions to manage their chronic conditions.

Taylor and colleagues[9] interviewed 219 pa-tients with hypertension to learn how controllingtheir blood pressure related to their more abstracthigher-level goals. Patients with hypertensionidentified maintaining an active lifestyle or main-taining an acceptable QOL as their higher-levelgoals. Additionally, hypertensive women saidachieving self-reliance was their goal for control-ling blood pressure. According to self-regulationtheory, patients who relate blood pressure con-trol (immediate clinical goal) to their overallQOL or maintaining an active lifestyle (higher-level goal) will make a greater effort to controltheir blood pressure.

Many patients take medication for multipleconditions. Therefore, this research asks patientsto identify immediate goals or reasons for takingmedication for their chronic conditions. For ex-ample, a patient may have arthritis and diabetesmellitus. This patient may be taking medicationto achieve relief from symptoms associated withpoor control of both conditions. Symptom con-trol (clinical goal) is expected to relate to a higher-level goal such as QOL. Also, patients who seek toachieve their goals can identify barriers and fa-cilitators that have prevented them or assisted

Patient Goals for Taking Medication 213


them, respectively. These factors can impact thesense of control patients may have about their ill-ness. The objectives of this study were

1. to identify higher- and lower-level goals forpatients using medication;2. to determine if there is a relationship betweenhigher- and lower-level goals; and3. to identify barriers and facilitators to achiev-ing patient goals.

Methods

The study design was prospective, cross-sectional, using survey methodology for datacollection. The target study population was re-sidents from oneMidwestern state (Michigan), atleast 45 years of age, taking prescription medi-cation for arthritis, hypertension, diabetes, orheart disease. These chronic conditions were se-lected because of their prevalence in the US.[1]

Patients could have more than one of the listedchronic conditions. The investigators selectedthis particular state as a matter of convenience.

Measures

Questions to describe patient demographics(age, race, income, and education), medicationuse (number of prescription medication, dollarsper month out-of-pocket expenditures, and typeof prescription drug insurance), medication-related goals, and barriers and facilitators toachieving these goals were included in the survey.The goals questions were developed using thegoals identified in Taylor and colleagues.[9] Pa-tients were asked to identify reasons for usingtheir medication. They selected the most im-portant of those reasons. The reason for choosingthe medication was defined as a lower-level goal.Next, patients were asked to select goals based onwhat they wanted to achieve or what they werestriving for by taking their medication. Theserepresented the higher-level goals. Then theyselected their most important goal.

Survey questions identifying barriers and fa-cilitators to achieving the medication-relatedgoals were based on the medication adherencestudies.[10-13] Patients selected barriers and facil-itators that were significant to them from the listof barriers and facilitators with an open-endedoption provided. Patients then selected the mostsignificant facilitator and barrier relevant to theirachieving their medication-related goal. The sig-nificance scale ranged from not at all significant(0) to very significant (3). The study questionswere included in a larger six-page survey devel-oped to describe consumer use of medication.The survey was reviewed by two other researchersfor content validity. The survey was tested andevaluated by ten patients to identify any confus-ing or misleading questions.

Sampling Strategy

An existing sampling frame of patients takingprescription medication for the specific chronicconditions was not available. A two-step sampl-ing process was used to identify eligible patients.First, a market research firm provided a list ofrandomly selected persons (n = 1600) living in thestate and who were 45 years of age and older.This age group was selected because they usemore prescription medications for chronic medi-cal conditions than younger age groups.[14] Thelist served as the initial sampling frame. Each ofthese persons received an invitation to participatein the study. A screening question on the first pageof the questionnaire asked the state residents ifthey were currently taking prescription medica-tion for (1) hypertension; (2) arthritis; (3) diabetes;or (4) heart disease. Qualifying participants con-tinued to answer the questions on the surveywhile others returned the survey unanswered.

A sample size of 169 completed surveys wasneeded to provide a statistically significant re-presentative measure of the likelihood and sig-nificance scales (alpha 0.05 and e = 0.075);[15] 1however, we oversampled the target population

1 n = (Za ·s/e)2 where Za is the Z score associated with the probability of a Type 1 error, s is the populationstandard deviation, Deming estimate was used to estimate s ~ (Range/6). For a measure ranging 1 through 5,Deming estimate for s is 4/6 or 0.67.



to accommodate for a non-specific mailing list andexpected response rate. We estimated 1600 con-sumer names be randomly selected to provide anadequate sample size, on an estimated 44% of thepopulation 45 years of age or older, the pre-valence of the chronic conditions (30% for hyper-tension),[14] and response rate to similar surveyresearch found in the literature (35%).[16] Quali-fying residents were asked to complete the surveyand to return it in an enclosed postage paid en-velope. A second mailing to non-respondents wasmailed out 4 weeks after the first mailing. TheUniversity Institutional Review Board approvedthe study protocol.

The potential for survey response bias wasevaluated using multiple methods. Respondentdemographics were compared with populationparameters to determine if the study participantswere comparable to the population. Also, sincelate responders are similar to non-respondents,[17]

early and late responder demographics were com-pared to identify potential bias. Univariate ana-lysis was conducted for all comparisons, usinganalysis of variance (parametric) or chi-squareanalysis (non-parametric measures) at the 0.05level of significance.

The first and third objectives of the study wereachieved by reporting descriptive statistics toidentify medication goals from the patient per-spective. Objective 2 was addressed by comparingthe higher- with the lower-level goals using chi-square analysis. All statistical analysis was con-ducted at the 0.05 level of significance using SPSSfor Windows, version 16.0.

Results

There were 372 respondents who agreed toparticipate in the study (24% response rate) and292 of the responders were at least 45 years oldand taking at least one prescription medicationfor arthritis, hypertension, diabetes, or heartdisease, and completed the survey. There weresignificantly fewer women and fewer respondents

in the lower income group (less than $US18 500annual household income) completing the sur-veys in the first mailing. Therefore, there was apotential under-representation of these patientgroups. The mean age of the respondents was61 years (standard deviation [SD]= 11.5 years). Therespondents could be characterized as Caucasian(90%), male (62%), with a high school diploma(highest achieved education level) [44%], withannual household income between $US35 000and $US88 000, with private prescription druginsurance paid by their employer, and with anaverage monthly out-of-pocket expenditure lessthan $US100.

The respondent demographics were comparedwith state demographics for those aged ‡45years.2 There were more men in the study sample(60%) when compared with the percentage ofmen in the state population (47%). The state-widedata of mean age (60.4 years) and race distribu-tion (85%Caucasian and 11%African American)were similar to the survey respondents.[18]

Themost common chronic conditionwas hyper-tension (77%), which was higher than the na-tional average for this age group. The prevalenceof hypertension in the US for individuals agedbetween 45 and 64 years and ‡65 years is 33% and53%, respectively.[19] The median number of co-morbidities in this study was two. The meannumber of total prescription medications was4.85 (SD 3.29).

Sex was the only demographic that correlatedwith the medication use measures. Women re-ported taking significantly more prescriptionmedication (average 5.7, SD 3.8) than men (aver-age 4.4, SD 2.9). A significantly higher percentageof women (31%) reported taking prescriptionmedication for arthritis than men (16%; p< 0.05).

The relationship between the higher- and lower-level goals was evaluated by asking patients toidentify the most important higher- and lower-level goals among all they identified as relevantas shown in table I. The most common lower-level goal for patients was ‘prevention of fu-ture problems’, followed by relief of symptoms.

2 It would be more accurate to compare demographics within a disease category, but this information is notavailable at the state level. The best we could get is for the age group segment of the population.



Approximately 52% of the respondents whosemost important higher-level goal was ‘improvingor maintaining their quality of life’ identified‘preventing future problems’ as their most im-portant lower-level goal. An equal percentage ofthose choosing the higher-level goal ‘allowingyou to carry out daily activities on your own’selected ‘relief of symptoms’ (38%) or ‘preventionof future health problems’ (38%) as their mostimportant lower-level goals. The majority of pa-tients with ‘living longer’ as their higher-level goalselected ‘prevention of future health problems’(64%) as their most important lower-level goal.The relationship between the higher- and lower-level goals was evaluated using Pearson chi-squareanalysis. This relationship was significant at the0.03 level of significance.

We ran chi-square analysis for each sexgroup and for age groups 45–64 years and‡65 years. There was a significant difference be-tween age groups (p= 0.02).More patients ‡65 yearsold chose ‘allowing you to carry out daily activ-ities on your own’ (33%) as their higher-level goalversus the younger group (14%). The most com-mon lower-level goal related to achieving thishigher-level goal was ‘prevention of future healthproblems’ for the older age group. More patientsin the younger age group versus the older agegroup chose ‘allowing you to care for your familyand others’ (12% vs 8%), ‘improving or main-taining your quality of life’ (52% vs 42%), and‘living longer’ (22% vs 18%) as their most im-

portant higher-level goal. The comparison ofhigher- and lower-level goals between men andwomen did not result in finding statistically sig-nificant differences. However, there were someinteresting observations. More women chose‘improving quality of life’ as the most importanthigher-level goal (55%) thanmen (32%).Moremenchose ‘living longer’ (24%) than women (15%).

Good communication between the patient andthe doctor (35%) and the effectiveness of the drugproduct (32%) were the most important factors inhelping patients to achieve their goals (see table II).The ability of the patient to monitor their condi-tion was the third most important factor selected(20%). We found a statistically significant relation-ship between the patient-perceived likelihood ofachieving their goals and the significance ratingof the facilitators (Pearson correlation= 0.226,p = 0.000).

Respondents identified barriers to achievingtheir medication-related goals. Themost significantbarrier was medication costs (30%), followed bydrug adverse effects (25%) and lack of drug effec-tiveness (20%) [see table II]. Approximately, two-thirds of the patients who identified medicationcosts as a barrier had prescription drug insurance.

Patients who had not yet achieved their higher-level goals (n= 91) were asked to identify importantbarriers (see table III). A similar percentage ofpatients across condition groups identified costof the medication as a barrier. Many patientsin our sample had multiple chronic conditions;

Table I. Relationship between most important higher- and lower-level goals related to medication use; n (% of higher-level goal)a

Lower-level goal Higher-level goals Total

ability to carry out daily

activities on your own

ability to care for your

family or others

improving or maintaining

your quality of life

living longer

Relief of symptoms 18 (38) 6 (26) 27 (24) 10 (20) 61

Prevention of future health

problems

18 (38) 12 (52) 60 (52) 32 (64) 122

Doctor recommendation 7 (15) 1 (4) 12 (10) 5 (10) 25

Improving or maintaining

quality of lifeb1 (2) 2 (9) 15 (13) 1 (2) 19

Ability to carry out daily

activities on your ownb4 (8) 2 (9) 1 (1) 2 (4) 9

Total 48 (100) 23 (100) 115 (100) 50 (100) 236 (100)

a Pearson chi-square statistic 23.0 (p = 0.028) for 4· 5 table.

b These goals were viewed as lower-level goals for certain patients.



therefore, we were not able to compare theimportant barriers by disease category. However,we separated those patients with a specificchronic condition and those without that condi-tion and made comparisons (table IV). Morepatients with diabetes (47%) than patientswithout diabetes (27%) stated that medicationcosts were a significant barrier to achieving theirhigher-level goals (p= 0.03). More patients witharthritis (42%) than those without arthritis (16%)found the lack of drug effectiveness to be a sig-nificant barrier to achieving their high-level goal(p = 0.05).

Discussion

Many patients have multiple health conditions.How do patients with multiple health conditionsmanage their care? The theory of self-regulationoffers insight to this question by suggesting thatpatients strive towards goals that address theirillness. Their behavior is likely to be driven bylower-level goals that are strongly and signifi-cantly related to higher-level goals.

Patients taking prescription medication for ar-thritis, heart disease, diabetes, and/or hypertensionwere surveyed in this study to learn about their

Table II. Facilitators and barriers identified as most important in helping patients to achieve or maintain their medication-related goalsa

Facilitators and barriers Patients

[n (%)]

Significance to goal achievementb

[mean (SD)]

Facilitators

Good communication between myself and the doctor 96 (35) 2.89 (0.32)

Effectiveness of the drug product 89 (32) 2.85 (0.39)

Patient ability to monitor condition 54 (20) 2.83 (0.38)

Reminder devices (pill boxes, alarms, calendars, etc.) 14 (5) 2.71 (0.47)

Family support 12 (4) 2.5 (0.67)

Good communication between myself and the pharmacist 2 (<1) 3.0 (0.0)

Barriers

Medication costs 28 (30) 2.81 (0.40)

Drug adverse effects 23 (25) 2.5 (0.60)

Lack of drug effectiveness 20 (22) 2.60 (0.60)

Not taking the medication as I am supposed to 12 (13) 2.25 (0.87)

Communication difficulty 3 (3) 3.00 (0.00)

Not being sure how to take my medication 1 (1) 1.00

a 16 respondents did not answer this question.

b Significance scale: 0 =not at all significant to 3= very significant.

Table III. Comparison of most important patient-perceived barriers to achieving medication-related goals among chronic conditions for

patients reporting not achieving their higher-level medication goal (% of patients in chronic condition category)a,b

Perceived barrier Diabetes mellitus

(n = 21)Hypertension

(n =64)Heart disease

(n =31)Arthritis

(n= 26)

Medication costs 43 38 45 35

Drug adverse effects 24 25 26 12

Lack of drug effectiveness 0 19 13 39

Not taking the medication as I am supposed to 24 11 10 8

Communication difficulty 0 4 3 0

Not being sure how to take my medication 5 0 0 0

a Patients may be in multiple disease categories; therefore, statistical analysis was not conducted.

b The number of responses is fewer, because the question excluded those who said they achieved their medication-related goal.



goals. These patients had both lower- and higher-level goals. This finding is supported by Taylorand colleagues.[9] The most common lower-levelgoal was ‘preventing future health problems’.‘Improving or maintaining quality of life’ was themost common higher-level goal. A significantcorrelation between these two types of goals wasfound. Approximately half of the respondentsidentified ‘prevention of future health problems’as a lower-level goal, with ‘improving or main-taining their quality of life’ as the associatedhigher-level goal. We expect that these patientswill take their medication to prevent future healthproblems in order to maintain or improve theirQOL.

There were differences in the distribution oflower- and higher-level goals among age andsex groups. More elderly patients (‡65 yearsof age) associated ‘prevention of future healthproblems’ with ‘living more independently’ (42%)than those in the younger age group. ‘Livingmore independently’ is a more desirable higher-level goal in the elderly group in this study than‘improving or maintaining quality of life’. Morewomen chose ‘improving quality of life’ (55%) asa higher-level goal thanmen (32%), whereas moremen chose ‘living longer’ (24%) than women(15%). More women chose ‘relief of symptoms’(34%) than men (21%) and more men chose‘prevention of future health problems’ (59%)than women (36%). Although these findings arenot significant, future studies should explore sexdifferences in goal-directed health behavior.Communication strategies should accommodatefor these differences, since theoretically lower-level goals most relevant to the higher-level goalsshould drive patient behavior.

This study identified lower- and higher-levelgoals associated with medication use. A signifi-cant and positive relationship was found betweenthese two types of goals by asking patients toidentify their lower-level goal (immediate reason)for taking medication and their higher-level goal(what they are striving to achieve).

What helps patients to achieve theirmedication-related goals? In this study, consumers felt that(i) good communication with their doctors (35%);(ii) drug product effectiveness (32%); and (iii) theirability to monitor their condition (20%) helpthem to achieve their medication-related goals.The evidence shows that slightly more patientsconsider good communication with their doctorsmore helpful to achieve their goals than an ef-fective drug product. Other studies have shownthat effective communication between patientsand physicians can impact their decision to ad-here to medication therapy.[20,21] For example,good communication with the physician can in-form patients about their illness, their symptoms,causes, timeline, consequences, and control. Ill-ness identity,[22] timeline,[23] and consequence[24]

have been found by other researchers to be sig-nificantly related to medication adherence inspecific chronic conditions.

The theory of self-regulation offers great op-portunity for researchers wishing to understandpatient decision making in the self-managementof health conditions. Future research should de-velop validated tools to measure gaps betweenlower- and higher-level goals, and the impact of thisrelationship on behavior. The five characteristicsof illness representation and their impact onforming lower-level goals with respect to higher-level goals deserve further study.

Table IV. Comparison of patient-perceived barriers for patients with and without select chronic conditions (% of patients in each category)a

Perceived barrier Patients with

diabetes mellitus (n = 19)Patients without

diabetes (n =66)Patients with

arthritis (n= 24)Patients without

arthritis (n = 61)

Communication difficulty 0 5 0 5

Drug adverse effects 26 27 13 33

Lack of drug effectiveness 0 30 42 16

Medication costs 47 27 38 30

Not taking medication as directed 26 11 8 16

a Significant chi-square p = 0.03 (for perceived barriers in diabetics vs no diabetes); p = 0.05 (for perceived barriers in arthritics vs no arthritis).



Limitations

The generalizability of the study is limited toconsumers in the study region. The response ratewas 24%, with evidence of response bias againstwomen and people of lower income groups. Fu-ture studies can extend the scope to other regionsof the US, since cultural or other regional differ-ences may result in different medication-relatedgoals or barrier/facilitators to achieving thosegoals. Similarly, studies of women and disadvan-taged populations should be conducted, particu-larly to identify potential barriers to achievingmedication-related goals. Finally, the data werecollected using surveymethodology and thus havethe potential limitations of self-reported data.

Conclusions

There is a significant and positive relationshipbetween the lower- and higher-level goals. Health-care providers can work with patients to achievetheir goals. Good communication with the pre-scriber and the effectiveness of the drug productwere identified as the most important facilitatorsby one-third of the respondents. Future researchshould study if relating the impact of good symp-tom control or the reduction of future health risksto QOL or longevity, as deemed relevant by thepatient, influences medication adherence behavior.

Acknowledgments

The following Pharm.D. candidates were part of a re-search team that helped in the development of the survey in-strument: Kristin Phillips and Yvonne Xie. Drs Leslie Shimp,Caroline Gaither, Nancy Lewis, and Anagha Nadkarni as-sisted in the review of the manuscript. Their contributionprovided significant improvements in the draft versions ofthe manuscript.This project was funded by the University ofMichigan College of Pharmacy.

The authors do not have any conflicts of interest or fi-nancial interests in any product or service discussed in themanuscript, including grants (pending or received), employ-ment, gifts, stock holdings or options, honoraria, con-sultancies, expert testimony, patents, and royalties.

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Correspondence: Dr SuzanKucukarslan, College of Pharmacy,University of Michigan, 428 Church Street, Ann Arbor, MI48109-1065, USA.E-mail: [email protected]



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