factors affecting medication adherence in rheumatoid arthritis

208 Pages·2013·3.7 MB·English

FACTORS AFFECTING MEDICATION ADHERENCE IN
RHEUMATOID ARTHRITIS

Boitshoko Oageng Kobue

A dissertation submitted to the Faculty of Health Science,
University of the Witwatersrand, in fulfilment for the degree
of Master of Science in Medicine

Johannesburg, 2013
DECLARATION

I, Boitshoko Oageng Kobue, declare that “FACTORS AFFECTING
MEDICATION ADHERENCE IN RHEUMATOID ARTHRITIS” is my own
work. It is being submitted for the degree of Master of Science in
Medicine in the University of the Witwatersrand, Johannesburg. It has
not been submitted before for any degree or examination at this or any
other University.

Boitshoko Oageng Kobue

..................................................................
The ............... day of ...................................................., 2013

ii
DEDICATION

This dissertation is dedicated to my parents, Monnana and Mumsy
Kobue, who have always supported my dreams and quest for higher
education. I would not have come this far had it not been for your
inspiring words and unwavering faith in my abilities. I will remain
eternally grateful for your encouragement during the times I felt like
giving up. I hope I have made you proud.

iii
PRESENTATIONS ARISING FROM THIS DISSERTATION
Poster Presentations
Boitshoko Kobue, Jennifer Watermeyer, Shirra Moch, Mohammed Tikly.
Factors Affecting Medication Adherence in Rheumatoid Arthritis. Wits
Faculty of Health Sciences Research Day and Postgraduate Expo,
Johannesburg, 19 September 2012.

Boitshoko Kobue, Shirra Moch, Jennifer Watermeyer, Mohammed Tikly.
Factors Affecting Medication Adherence in Rheumatoid Arthritis.
University of the Witwatersrand 4th Cross-Faculty Postgraduate
Symposium, Johannesburg, 19 and 22 October 2012.

Oral Presentations
Boitshoko Kobue, Shirra Moch, Jennifer Watermeyer, Mohammed Tikly.
Factors Affecting Medication Adherence in Rheumatoid Arthritis. Annual
Congress of the South African Society for Basic and Clinical
Pharmacology in association with the Department of Family Medicine
(University of Pretoria) and Toxicology Society of South Africa, Pretoria,
29 September – 2 October 2012.

Boitshoko Kobue. Adherence to Therapy Amongst RA Patients. South
African Nurses in Rheumatology Symposium, Stellenbosch, 2-4
November 2012.

iv
ACKNOWLEDGEMENTS
I would like to express the deepest gratitude to my supervisor Mrs
Shirra Moch for allowing me the opportunity to pursue this study. I have
no doubt that I would not have been able to come this far without your
enthusiasm and optimism. You believed in my vision even before I could
define it. Thank you for the emotional and intellectual support. I have
learnt more from you than I had ever imagined.

To my second supervisor, Dr Jennifer Watermeyer, you breathed new
life into my study when I was about to give up hope. Thank you for
believing in me and helping me through the toughest part of this
research process. Your cheerful demeanour always lifted my spirits and
helped me to keep the faith. You walked me through the “foreign land”
that was qualitative research and I greatly appreciate your patience and
assistance throughout the writing process.

To Professor Mohammed Tikly, Dr Bridget Hodkinson and Sister Nomsa
Mavuso, thank you for welcoming me into your clinic and helping me
throughout my data collection phase. Your advice and support were
greatly appreciated.

To Sister Keletsto Mmoledi, thank you for your assistance during the
analysis phase.

My boundless appreciation goes out to the staff members of the
Pharmacology Department who assisted me during various stages of my
research.

To my sister, Kanyi, and my friend Sbosh, your support, advice and
continuous encouragement helped me to complete this research. I was
blessed to have you by my side throughout my masters journey.

v
ABSTRACT
Factors Affecting Medication Adherence in Rheumatoid Arthritis
Introduction: Rheumatoid arthritis (RA) is a chronic inflammatory
disease that typically affects the wrists and small joints of the hands and
feet. Its progressive nature can result in severe deformities and the
inability to perform daily tasks. RA requires lifelong medication to
ameliorate symptoms of the disease. The lifestyle changes necessary to
achieve continuing functionality include taking medication daily. This is
an area that has not been adequately researched.
Aim: To qualitatively determine the factors affecting RA patients’
adherence to chronic prescribed medication.
Methods: A semi-structured interview schedule was used to interview
18 patients from an out-patient Rheumatology Clinic at a Johannesburg
hospital. The patients were purposively selected and invited to
participate in the study. The individual interviews were conducted in the
home language of the participant and video-recorded. Interview were
then translated into English and transcribed. The patient accounts of
their medication taking habits were compared to their hospital records
regarding prescribed medication. Thematic Analysis was used to identify
the prominent issues raised in each interview. These categories were
then grouped into themes that occurred across the data set. Interviews
with two members of staff and ethnographic observations were also
conducted to get a better understanding of how the clinic functions.
Findings: Four main themes were identified. Firstly, the effect of RA on
the living experiences of patients. This dealt with the manner in which
RA affected their quality of life and how those experiences affected
adherence. Secondly, interactions with medication, which explored the
manner in which patients used both prescribed and non-prescribed
medication. Thirdly, patients’ experience of healthcare services. This
explored the functioning of health systems and how patient adherence
vi
can be subsequently affected. Lastly, level of understanding and access
to information which explored the effect of the knowledge deficit that
exists in patients regarding biomedical concepts and how that
contributes to their adherence levels.
Discussion: The findings showed that more can still be done by
healthcare professionals to improve patients’ experience of the
healthcare system, and to promote patient adherence to medication.
The factors that affect adherence provide many avenues for further
research, areas in which interventions can be implemented to improve
the quality of healthcare being provided to South African communities.

vii
TABLE OF CONTENTS

DECLARATION ....................................................................................... ii
DEDICATION ........................................................................................ iii
PRESENTATIONS ARISING FROM THIS DISSERTATION .......................... iv
ACKNOWLEDGEMENTS ......................................................................... v
ABSTRACT ............................................................................................ vi
TABLE OF CONTENTS .......................................................................... viii
LIST OF TABLES .................................................................................................. xii
LIST OF FIGURES ................................................................................................ xii
LIST OF ABBREVIATIONS ................................................................................... xiii
CHAPTER ONE: INTRODUCTION ............................................................ 1
OUTLINE OF THE RESEARCH ................................................................................ 3
CHAPTER TWO: BACKGROUND – RHEUMATOID ARTHRITIS AND ITS
TREATMENT .......................................................................................... 7
RHEUMATOID ARTHRITIS ................................................................................... 7
TREATMENT FOR RHEUMATOID ARTHRITIS ....................................................... 10
CONVENTIONAL MEDICINES USED IN THE TREATMENT OF RHEUMATOID
ARTHRITIS ......................................................................................................... 13
Non-Steroidal Anti-Inflammatory Drugs .............................................................. 13
Disease-Modifying Anti-Rheumatic Drugs ............................................................ 14
Glucocorticosteroids ............................................................................................. 16
Biologicals ............................................................................................................. 16
COMPLEMENTARY MEDICINES USED IN THE TREATMENT OF RHEUMATOID
ARTHRITIS ......................................................................................................... 24
Traditional Medicines ........................................................................................... 24
Herbal Remedies ................................................................................................... 26
NON-MEDICINAL TREATMENT FOR RHEUMATOID ARTHRITIS ............................ 27
LEGAL ASPECTS OF MEDICATION ....................................................................... 29
CHAPTER THREE: LITERATURE REVIEW ................................................ 32
viii
MEDICATION TAKING PRINCIPLES ..................................................................... 32
THE SOUTH AFRICAN HEALTHCARE SYSTEM....................................................... 36
ADHERENCE IN SOUTH AFRICA .......................................................................... 38
MEASUREMENT OF ADHERENCE........................................................................ 40
HEALTHCARE PROVIDER-PATIENT COMMUNICATION ........................................ 41
CHAPTER FOUR: METHODS ................................................................. 46
AIM AND OBJECTIVES ........................................................................................ 46
RESEARCH DESIGN ............................................................................................ 46
RESEARCH SITE .................................................................................................. 47
Clinic staff ............................................................................................................. 50
Patient referral to the clinic .................................................................................. 51
Patient education and counselling ....................................................................... 51
PARTICIPANTS ................................................................................................... 52
PILOT STUDY ..................................................................................................... 55
DATA COLLECTION ............................................................................................ 56
Video-recorded interviews ................................................................................... 56
Medical record reviews ........................................................................................ 59
Ethnographic principles ........................................................................................ 59
DATA ANALYSIS ................................................................................................ 60
RIGOUR ............................................................................................................ 63
ETHICAL CONSIDERATIONS ................................................................................ 65
CHAPTER FIVE: FINDINGS .................................................................... 67
EFFECTS OF RA ON LIVING EXPERIENCES ............................................................ 69
Effect on physical abilities .................................................................................... 70
Emotional aspects ................................................................................................. 71
Support System ..................................................................................................... 74
INTERACTIONS WITH MEDICATION ................................................................... 76
Co-morbidities ...................................................................................................... 77
Access to medication ............................................................................................ 78
Self Medication ..................................................................................................... 82
Side Effects ........................................................................................................... 85
Generic Substitution ............................................................................................. 87
ix
Burden of taking daily medication ....................................................................... 90
LEVEL OF UNDERSTANDING AND ACCESS TO INFORMATION ............................. 92
Influence of cultural and social beliefs ................................................................. 93
Communication with healthcare providers .......................................................... 96
Use of Technology ................................................................................................ 99
Language barriers ............................................................................................... 100
EXPERIENCE OF HEALTHCARE SERVICES ........................................................... 103
Local healthcare experience ............................................................................... 103
Out-patient RA clinic experience ........................................................................ 106
Hospital pharmacy experience ........................................................................... 107
CHAPTER SIX: DISCUSSION ................................................................ 111
PAIN AND DISABILITY ...................................................................................... 112
MEDICATION AND MEDICATION TAKING ......................................................... 119
THE NEED FOR INFORMATION ......................................................................... 126
Summary of Recommendations ......................................................................... 128
IMPLICATIONS ................................................................................................ 128
Implications for practice and policy ................................................................... 128
Implications for theory ....................................................................................... 129
Implications for future research ......................................................................... 130
LIMITATIONS................................................................................................... 131
CHAPTER SEVEN: CONCLUSION ......................................................... 132
REFERENCES ...................................................................................... 135
APPENDICES ...................................................................................... 156
APPENDIX A: SEMI STRUCTURED INTERVIEW SCHEDULE .................................. 156
APPENDIX B: MORISKY MEDICATION ADHERENCE SCALE ................................. 162
APPENDIX C: TRANSCRIPT BACK TRANSLATION REPORT .................................. 163
APPENDIX D: SUMMARY OF INTERVIEWS ........................................................ 164
APPENDIX E: HOSPITAL PERMISSION TO CONDUCT RESEARCH ......................... 179
APPENDIX F: CLINIC PERMISSION TO CONDUCT RESEARCH .............................. 180
APPENDIX G: ETHICS APPROVAL CERTIFICATE .................................................. 181
APPENDIX H: CHANGE OF TITLE APPROVAL ..................................................... 182
x