Health inequalities in medication adherence in those with cardiometabolic disease(s)

Supervisors:

• Dr Patrick Highton ph204@le.ac.uk
• Dr Riya Patel  rp526@leicester.ac.uk
• Dr Mark Funnell  mpf13@leicester.ac.uk
• Professor Kamlesh Khunti kk22@le.ac.uk

Project available to UK applicants only.

Significant health inequalities also exist cardiometabolic disease and medication adherence. For instance, in the UK, hypertension is significantly more prevalent in ethnic minority populations, and these populations may also not achieve post-diagnosis blood pressure control comparable to that of their white counterparts [7]. Consequently, certain ethnic minority populations, including South Asian and Afro-Caribbean, are at greater cardiovascular (CVD) risk than Europeans [8, 9]. CVD prevention is therefore vital in these groups. However, ethnic minority populations display increased risk of antihypertensive medication non-adherence when compared to the white population [10-12]. This is potentially driven by factors such as differing cultural beliefs, past healthcare experiences, communication barriers, lack of trust, perceived discrimination or reduced health literacy [13, 14].

The identification of medication non-adherence in primary care typically relies on patient self-report or expert opinion, despite being often inaccurate, and may also be heavily influenced by equality-related factors such as patient-physician communication or trust. Recent advances in adherence testing may provide more robust alternative methodologies. Chemical adherence testing (CAT) provides a direct and objective measure of recent medication adherence [15] and can identify previously unknown antihypertensive medication non-adherence. However, all methods of measuring medication adherence may be subject to health inequalities due for instance to cultural acceptability or attitudes. There is therefore a need to investigate this to inform future implementation and design of therapeutic interventions.

Methodology

The aims, objectives and methodology of this studentship will be refined and finalised by the successful candidate once they have begun the studentship, with support from the supervisory team. However, the currently proposed aims and methodology are summarised below.

Aims: The aim of this project will be to investigate health inequalities in medication adherence measurement and/or outcomes in those with cardiometabolic diseases, with a particular focus on hypertension.

Methodology:It is likely that this PhD project will employ a mixed-methods approach. The project plan and methodology will be refined and finalised when the successful candidate has begun their studentship, however the following outline is currently proposed:

1. Systematic review of factors that predispose to risk of medication non-adherence
2. Secondary analysis of pre-existing data to look at determinants of medication non-adherence and association with health outcomes
3. Qualitative investigation into factors associated with medication non-adherence and interventions that individuals living with cardiometabolic disease think would work to support medication adherence

The successful applicant will be embedded within a team of experts in cardiometabolic disease and ethnic minority health and receive training and support in a wide variety of research methodologies where necessary. The PhD project will be integrated into a vibrant postgraduate research community within the Diabetes Research Centre and the Centre for Black, Minority and Ethnic Health at the University of Leicester, and help advance the aims of the Applied Research Collaboration (ARC) East Midlands and the National Institute of Health Research Leicester Biomedical Research Centre (BRC).

References: 

1. Organization, W.H., Adherence to long-term therapies: evidence for action. 2003: World Health Organization.
2. Shin, S., et al., Effect of antihypertensive medication adherence on hospitalization for cardiovascular disease and mortality in hypertensive patients. Hypertension Research, 2013. 36(11): p. 1000-1005.
3. Cutler, R.L., et al., Economic impact of medication non-adherence by disease groups: a systematic review. BMJ open, 2018. 8(1).
4. Trueman, P., et al., Evaluation of the scale, causes and costs of waste medicines. Report of DH funded national project. 2010.
5. Kim, S., et al., Measuring medication adherence in older community-dwelling patients with multimorbidity. European journal of clinical pharmacology, 2018. 74: p. 357-364.
6. Foley, L., et al., Prevalence and predictors of medication non-adherence among people living with multimorbidity: a systematic review and meta-analysis. BMJ open, 2021. 11(9): p. e044987.
7. Cappuccio, F.P., A. Barbato, and S.M. Kerry, Hypertension, diabetes and cardiovascular risk in ethnic minorities in the UK. The British Journal of Diabetes & Vascular Disease, 2003. 3(4): p. 286-293.
8. Wild, S.H., et al., Mortality from all causes and circulatory disease by country of birth in England and Wales 2001–2003. Journal of public health, 2007. 29(2): p. 191-198.
9. Tillin, T., et al., Ethnicity and prediction of cardiovascular disease: performance of QRISK2 and Framingham scores in a UK tri-ethnic prospective cohort study (SABRE—Southall And Brent REvisited). Heart, 2013.
10. Holmes, H.M., et al., Ethnic disparities in adherence to antihypertensive medications of medicare part D beneficiaries. Journal of the American Geriatrics Society, 2012. 60(7): p. 1298-1303.
11. Donneyong, M.M., et al., Examining the Drivers of Racial/Ethnic Disparities in Non-Adherence to Antihypertensive Medications and Mortality Due to Heart Disease and Stroke: A County-Level Analysis. International Journal of Environmental Research and Public Health, 2021. 18(23): p. 12702.
12. Gu, A., et al., Racial and ethnic differences in antihypertensive medication use and blood pressure control among US adults with hypertension: the National Health and Nutrition Examination Survey, 2003 to 2012. Circulation: Cardiovascular Quality and Outcomes, 2017. 10(1): p. e003166.
13. Cuffee, Y.L., et al., Reported racial discrimination, trust in physicians, and medication adherence among inner-city African Americans with hypertension. American journal of public health, 2013. 103(11): p. e55-e62.
14. Alhomoud, F., et al., Medicine use and medicine-related problems experienced by ethnic minority patients in the United Kingdom: a review. International Journal of Pharmacy Practice, 2013. 21(5): p. 277-287.
15. Osman, H., R. Alghamdi, and P. Gupta, Review of the methods to measure non-adherence with a focus on chemical adherence testing. Translational Metabolic Syndrome Research, 2022. 5: p. 1-9.