As US demographics steadily shift towards minorities and immigrants from diverse backgrounds, health care workers must be prepared to face new cultural challenges that may impact health behaviors, including medication adherence in these populations.
Medications are increasingly prescribed by physicians for prevention and treatment of chronic diseases. However according to the World Health Organization (WHO), adherence rates for chronic medications average less than 50%.1 Additionally, an estimated one- to two-thirds of medication-related hospitalizations are thought to result from non-adherence to medications.2
Adherence can be defined as the extent to which person’s behavior corresponds with recommendations of health care providers.3 Unlike compliance, adherence is predicated on the patient’s active involvement in his or her own care and agreement to recommendations. Thus, adherence to medical therapy represents a key aspect of patient-centered treatment, influencing health system effectiveness, health care costs, and patient health outcomes.4,5
As US demographics steadily shift towards minorities and immigrants from diverse backgrounds, health care workers must be prepared to face new cultural challenges that may impact health behaviors, including medication adherence in these populations. Non-adherence to medications is often associated with out-of-pocket costs, past medication experiences, and even perceived need for certain medications.5 However, behaviors such as non-adherence can be further modified by individual patient-related factors such as socioeconomic status, acculturation status, and perceived social support.1,2,6
Medication Adherence in Latinos
Although the effects of poor medication adherence are common among patients with chronic diseases, there are significant disparities in adherence among underserved minority groups, such as Latinos.7—9 Although Latinos are not a homogenous group, in general significant disparities in the management and outcomes of cardiovascular disease, depression, HIV and asthma exist in this population compared with non-Latinos.10
Latino patients were found to have the poorest medication adherence on a nationwide internet survey, and although they had the lowest reported A1c, they were also the least likely to know their A1c.11 Another study assessed racial differences in medication adherence by evaluating medication possession ratios (MPRs) and found that Hispanic patients had significantly lower MPR relative to non-Hispanic whites.12 Capo-Ramos et al surveyed 4262 Medicaid patients over an 8-year period to assess the risk factors for the discontinuation of preventive asthma medications and found that Hispanics had a higher hazard for discontinuation.13
Increasing emphasis on self-management and adherence to complex chronic disease treatments may place an excessive stress burden on underserved Latinos who often lack the necessary coping resources and insight into their health.14 If the Latino population in the US is expected to triple in size by 2050,15 continued poor medication adherence among this high risk population could result in serious public health and economic consequences.5,6
The causes of disparities in adherence among Latinos often go beyond regimen-related factors and often involve unique patient-related factors that influence health beliefs, behaviors, and attitudes toward health care.6,16 These factors can directly or indirectly encourage harmful health behaviors, including nonadherence to prescribed medication therapy. In Latinos, lower levels of socioeconomic status, health literacy, and acculturation may contribute to health disparities by influencing knowledge and attitudes of health and interactions with health care providers.6,16
The purpose of this review is to describe these unique patient-related factors that act as barriers to medication adherence and drive health disparities among the Latino population. Within this context, medication non-adherence is conceptualized as a health risk behavior that (1) has direct and indirect health consequences and (2) is influenced by patient-related factors at the level of the individual, healthcare provider and health care system.
Acculturation refers to the process of cultural adjustment in which a person adapts the behaviors, attitudes, norms, and values of another host culture.17,18 Acculturation represents a major life event that taxes coping resources and affects perceptions of health and health care providers.
There is significant heterogeneity in health outcomes among Latino subgroups, which may stem from their different immigration and acculturation experiences.19 For immigrants, permanent relocation often includes a change in health beliefs and behaviors as they gradually relinquish their traditional practices and adopt new cultural practices.
Acculturation largely depends on immigrant status, social environment, and the extent to which multiple cultural traditions can be adopted or combined.17,20 Some studies suggest that less acculturated Latinos have decreased prevalence of chronic diseases such as hypertension and diabetes;21 however, they often have worse risk factor profiles, and are less likely to adhere to medical therapy.22,23
Since Latino immigrants suffer the most severe adjustment problems at the initial stages of transition when number of life changes is highest and coping resources are at their lowest,24 adherence to medical therapy may be affected during this vulnerable time. As acculturation increases, healthcare access and health literacy increase while many maladaptive behaviors such as poor diet, and substance abuse remain.14,16 In this context, poor medication adherence can be viewed as a maladaptive behaviour associated with low levels of acculturation and decreased control of chronic diseases such as hypertension and diabetes.14
Acculturation may further influence Latino beliefs and values, which in turn determine health behaviors and how an individual responds to an illness. Fatalismo is a common fatalistic belief among Latinos that illnesses are the will of God or from external forces of evil.25 A fatalistic belief in illness can lead to perceived lack of control over an illness and may affect patient provider interactions and attitudes toward adherence to therapy.25 These beliefs can contribute to stigma associated with certain mental and physical illnesses and a lack of awareness regarding available medical services.14,26
Discrimination can strongly influence patterns of acculturation and may in part explain disparities in health, as well as maladaptive health behaviors among underserved Latinos.27,28 For instance, among Latino HIV patients, discrimination experiences predicted poorer medication outcomes and health outcomes.10 Other studies have shown that perceived discrimination is associated with mistrust of health care providers and institutions and delays in filling prescriptions, which can lead to poor adherence and poor health outcomes.29,30
Adequate communication is often considered a key component to intercultural effectiveness and competence.24 Spoken language is often used as a proxy measure of acculturation and considered a predictor of satisfaction with patient-provider interactions.18 Language barriers have been associated with poorer quality care and dissatisfaction with care.31,32
Poor interactions with non-Latino health care providers can result in perceived lack of cultural sensitivity and control over the interaction.33 The perception of poor provider communication or lack of accommodation from the provider has been shown to negatively impact adherence among Spanish-speaking Latinos.3,22,34
Language concordance is an issue for Latino patients because a majority of healthcare providers identify as non-Latino and do not speak Spanish, which may amplify the cultural distance between the patient and the provider.
Social support refers to resources from a mutual network of family and friends that increase self-esteem.35 Adequate social support is a protective coping resource that can enhance self-management behaviors and physical health among less acculturated Latinos.16,35 An example of social support within the context of Latino culture is familismo, which refers to a strong sense of collectivism, and attachment to immediate and extended family members.
Among less acculturated immigrants, it is plausible that social support networks that include members from the host culture may also be important for learning beneficial self-management behaviors from the host culture. These social support structures provide a range of benefits ranging from emotional outlets and companionship, to financial assistance and caregiving that may buffer against the adverse effects of poor adherence.36
Higher levels of perceived social support are associated with increased use of preventative health care services, decreased morbidity and improved adherence and perception of illness.16 One cross-sectional analysis of diabetes control in community-dwelling Latino adults found that family support buffered the effect of cognitive decline on impairment of glycemic control.37
Health literacy (HL) is defined as the capacity to obtain and understand basic health information and skills needed to make health decisions.38 Lower HL has been shown to contribute to poor medication adherence in many populations including patients living with HIV,39 patients with gout,40 patients with asthma,41 and the elderly.42 Low HL is more common among minorities with lower socioeconomic status and lower English proficiency,43 where it can contribute to poorer lifestyle behaviors and self-management of diseases such as diabetes and hypertension.44
Although there are limited studies on health literacy and medication adherence in the Latino population,45 Latinos seem to be disproportionately affected by low HL with an estimated 41% lacking basic HL skills.46 A cross sectional analysis of 149 Hispanic patients with diabetes found that 40% of them had low health literacy, which was associated with being elderly and less educated as well as a longer duration of diabetes; however, they found that lower health literacy has a higher association with physician trust and medication adherence.47 An interview of 25 HIV positive Spanish-dominant Hispanics revealed that patients felt more comfortable with a Spanish-speaking provider, and suggested that having Spanish language tailored interventions may increase health literacy.48 The Institute of Medicine has recognized the potential for HL to impact chronic disease management and the need for quality care that is responsive to health literacy levels of Latinos.38
Among health providers there is growing interest in better understanding these patient-related factors to prevent disparities in medication adherence and improve health outcomes. As primary points of contact, pharmacists are uniquely trained to impact adherence by addressing regimen-related factors such as pill burden and side effects, though they often face intrinsic patient barriers such as illiteracy and personal health beliefs and practices.
Pharmacist-based interventions that incorporate medication therapy management have proven effective in improving adherence in general populations.49,50 Such patient-centered approaches to promoting adherence are meant to educate and provide insight into the reasons for the therapy.
However, high risk groups such as Latino immigrants are more likely to benefit from culturally competent pharmacist interactions that promote adherence to medical therapy by leveraging traditional cultural and social support resources.51,52 A randomized study of minorities (44% Hispanics) after a coronary stent found that patients who received a telephonic motivational interview had improved medication adherence after 12 months.53
Furthermore, less acculturated Latinos with limited health literacy will require more individually tailored approaches to improve adherence. Increased Spanish language fluency and appreciation of the underlying social structures of Latino cultural beliefs and values represent important first steps for pharmacists to improve perceptions of adherence among this population. Among underserved Latinos, a health promoter based program that includes pharmacists has been successful in promoting appropriate medication use by addressing adherence-related barriers through education and social support.54 However, more qualitative research into the effects of patient-related sociocultural factors is needed to improve pharmacists’ efforts to address adherence among individuals and communities.55
Roles of Minority Serving Institutions
Awareness of the sociocultural factors that influence views on health and adherence should begin early in the classroom before healthcare providers reach the workforce. Currently, minorities in the US comprise more than 25% of the total population but represent less than 10% of the health workforce. A shortage of minorities in the health workforce may be contributing to a lack of cultural concordance between Latino patients and providers, leading to poorer health outcomes and decreased health equity.
Minority serving institutions such as Historically Black colleges and universities (HBCU) or Hispanic Serving Institutions (HIS) are ideally positioned to contribute to an ethnically diverse and culturally competent health workforce. However, the health professional training programs offered at these institutions have failed to produce a significant impact on the number of minorities in the health workforce. These programs have the potential to broaden their mission to meet the evolving health care needs of local underserved minority communities by offering specialized culturally competent training to their students.
Munder Zagaar PharmD, PhD, is an assistant professor at the Texas Southern University College of Pharmacy and Health Sciences. Uche Anadu Ndefo, PharmD, BCPS, is an associate professor at the Texas Southern University College of Pharmacy and Health Sciences.