Implicit and explicit attitudes towards disease-modifying antirheumatic drugs as possible target for improving medication adherence.

M Van Heuckelum,M T Nurmohamed,C H M Van Den Ende,M Vervloet,L Van Dijk,L Vandeberg,R C F Hebing,A J Linn,S Van Dulmen,M Flendrie,B J F Van Den Bemt

doi:10.1371/journal.pone.0221290

Abstract

ObjectiveThis study aims to explore the contribution of implicit attitudes and associations towards conventional disease-modifying antirheumatic drugs (cDMARDs), alongside explicit measures, on medication-taking behaviour and clinical outcomes in adult patients with rheumatoid arthritis (RA).MethodsIn this observational study, implicit attitudes (positive-negative) and health-related associations (health-sickness) were measured with Single Category Implicit Association Tests, whereas explicit outcomes were measured with a bipolar evaluative adjective scale and the Beliefs about Medicines Questionnaire Specific. The primary outcome of this study was medication-taking behaviour subjectively measured by self-report (i.e. validated Compliance Questionnaire on Rheumatology) and objectively measured with electronic drug monitors over a 3 month period. Spearman rank correlations were used to describe correlations between implicit and explicit outcomes. Nested linear regression models were used to assess the additional value of implicit measures over explicit measures and patient-, clinical-, and treatment-related characteristics.ResultsOf the 1659 initially-invited patients, 254 patients with RA agreed to participate in this study. Implicit attitudes correlated significantly with necessity-concerns differential (NCD) scores (ρ = 0.13, P = 0.05) and disease activity scores (ρ = -0.17, P = 0.04), whereas implicit health-related associations correlated significantly with mean scores for explicitly reported health-related associations (ρ = 0.18, P = 0.004). Significant differences in age, number of DMARDs, biologic DMARD use, NCD-scores, and self-reported correct dosing were found between the four attitudinal profiles. Nested linear regression models revealed no additional value of implicit measures in explaining self-reported medication-taking behaviour and clinical outcomes, over and above all other variables.ConclusionImplicit attitudes and associations had no additional value in explaining medication-taking behaviour and clinical outcomes over and above often used explicitly measured characteristics, attitudes and outcomes in the studied population. Only age and NCD scores contributed significantly when the dependent variable was correct dosing measured with self-report.

Highlights

Significant differences in age, number of DMARDs, biologic DMARD use, necessity-concerns differential (NCD)-scores, and self-reported correct dosing were found between the four attitudinal profiles
Implicit attitudes and associations had no additional value in explaining medication-taking behaviour and clinical outcomes over and above often used explicitly measured characteristics, attitudes and outcomes in the studied population
Rheumatoid arthritis (RA) is a chronic inflammatory disease characterised by synovial inflammation, which can lead to irreversible articular damage, a decrease in physical functioning and quality of life, and eventually increased healthcare expenditures [1,2,3,4,5]

Summary

Introduction

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterised by synovial inflammation, which can lead to irreversible articular damage, a decrease in physical functioning and quality of life, and eventually increased healthcare expenditures [1,2,3,4,5]. An explanation for the ineffectiveness of adherence-improving interventions might be that previous studies have largely focused on patient’s explicit, ‘conscious’, evaluations of e.g. medication or medication-taking behaviour [11,12]. These interventions are often designed on the basis of theories such as the theory of planned behaviour and the health belief model, which form the backbone for understanding how explicit evaluations affect behaviour [11,12,13,14]. In contrast, has rarely tapped into this knowledge base, generally ignoring patients’ automatic associations with their medication or medication-taking behaviour.

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