Table 4 Barriers of medication adherence sorted by COM-B
COM-B | TDF | What needs to happen for target behavior to occur? | Information about barriers to medication adherence | Do factors/barriers need to change to perform target behavior (based on contextual analysis)? |
|---|---|---|---|---|
Physical capability | Physical skills | Being physically able to swallow pills and remember if already taken | Poor physical condition [50] a b | NO Physical limitations (e.g. cognitive function) which can’t change |
YES Limited physical stamina (e.g. fatigue, nausea) | ||||
Psychological capability | Knowledge | Knowledge why intake and timing of immunosuppressants is important | Lack of knowledge about medication and consequences [48, 50,51,52,53,54,55,56,57,58,59,60,61] a b Wrong information b Ambiguities / vague advise [50, 52, 53] a Unclear, where getting prescription from and which pharmacy [49,50,51, 57, 62] a b | YES Lack of knowledge about importance and consequences of medication (non-) adherence |
Behavioral regulation | Apply the knowledge of correct medication intake and timing in every aspect, applying if-then-rules Development of coping strategies for barriers | Lack of routine [51, 52, 55,56,57, 59, 63] a No sense of autonomy regarding medication intake [51] Longer time since transplantation [64] Current major life event (other priorities) [49, 53] Busy lifestyle [48, 49, 51, 54, 57] Alcohol and substance abuse [51] | YES Lack of procedural knowledge of medication intake YES Lack of behavioral regulation (e.g. self-monitoring) YES Lack of skills to develop coping strategies facing barriers | |
Memory, attention & decision processes | Notice and remember at prescribed time during daily life to take medication | Information overload b Forgetfulness [48, 49, 51, 52, 54,55,56,57, 65] a, poor executive function after transplantation [53, 65] Forgetting get a new prescription on time [49, 50, 54, 56, 57, 60] a b | YES Limitations in memory, concentration, attention & decision processes â‹„ Lack of awareness / recognition in daily life | |
Cognitive and inter-personal skills | Development of habit in correct timing and intake of medication, Skill to ask for help if needed | Unable to cope with changed prescription [54] Lack of psychological skills to fill pill boxes / prepare medication correctly [60] | YES Lack of habit-forming, goal-setting or action-planning skills | |
Physical opportunity | Environ-mental context and resources | Enough medication available, readily accessible at opportunities, enough reminder clues | Not having medicines when being away from home [48, 49, 54, 57] a Lack of cues [48,49,50, 52, 55,56,57, 60] a b Time of intake «does not fit» to lifestyle [48,49,50, 56, 57, 65] a Interruptions in daily routine [48,49,50, 52, 54, 56, 57] a Distance to clinic, no regular follow up [50] Travelling (e. g. to other time zone) [48, 49, 57] Changed time of intake due to clinical visits implies that it is not important [56, 57] a Complexity due to polypharmacy [48, 50, 51, 53, 56, 61] a b Barriers to take immunosuppressants [62] | YES Lack of facilitation via accessibility, possibility, easiness, availability, convenience YES Lack of facilitation via support for memory, concentration, attention |
Social opportunity | Social influence | Patient participation & empowerment regarding an increased awareness about that medication management is a shared duty of everyone involved in the care | Lack of family support (emotional, instrumental) [48,49,50,51,52,53, 55,56,57, 59, 61, 62, 65] a b Lack of social support [48, 49, 51, 53, 55, 56, 59, 61, 62, 65] b Lack of peer learning (blogs, internet forum, waiting room) [52, 53, 56, 61] a Incorrect lay knowledge from peers b Lack of positive and negative role models [58] Lack of individual support (by nurses, pharmacists) [50, 52, 53, 56] a Avoiding taking medication in public / in front of friends [56] Lack of comparison with worse ill people [56, 57] Lack of trusting partnership with health professionals [50, 53, 57, 59] Lack of attention from nurses / health care professionals [53, 55, 62] | YES Lack of positive role models YES Lack of social or peer support (e.g. patient empowerment / participation, private or, professional support) YES Lack of awareness that medication intake can be improved by of everyone involved in the care |
Automatic Motivation | Emotion | Positive emotions related to medication adherence | Feeling overwhelmed [58, 63] b Burnout / treatment fatigue [48, 52, 55, 57]; Depression [51, 57, 65] Low quality of life (direction of association unclear) [51] Negative emotions / attitude [49, 53, 58, 59]; Distress [51, 54] Desire for independence in self-management [52, 65] Nuisance due to repetitive reminder [57] Low gratitude toward medical team/donor [48,49,50,51,52, 54,55,56, 61] Tablet phobia (fear of swallowing tablets) [53]a | YES Lack of coping strategies YES Low relationship with health care provider YES Fear of embarrassment |
Reinforcement | Strategies for possible problems | Incompatibility of the immunosuppressants a b | YES Lack of problem solving strategies | |
Reflective Motivation | Intentions | Have willingness and a plan on correct intake and timing | Lack of intention to adhere [51] a Not interested in learning about medication before transplant [60] | YES Insufficient intention YES Insufficient goals |
Beliefs: consequences | Correct beliefs of resulting consequences of non-adherence | Beliefs in illness, medication and side effects [48, 50,51,52,53,54,55,56,57,58,59,60,61, 63] a b Lack of knowledge about consequences [48,49,50,51,52,53,54,55, 57, 60] a Consequences of MNA not clear (health belief) [51, 55] a b Blood test did not capture MNA [56] Establishing a personal leeway of time [49] Defining acceptable risks [52] | YES False beliefs about consequences | |
Beliefs: capabilities | Correct beliefs of capability in medication management | No confidence in self-management (mastery) [50,51,52,53, 58] Lack of problem solving competence and self-efficacy [50,51,52] a | YES False beliefs about own capabilities (e.g. self-efficacy) | |
Goals | Correct beliefs of own responsibility for outcomes | Lack of motivation to convalescence [55, 58] b Making medications a low priority [57] | YES False beliefs in own responsibility for wanted outcomes | |
Optimism | Confidence that desired goals will be achieved | Maladaptive coping [65] | YES Lack of adaptive coping strategies (to reduce stress) | |
Role and identity | Compatible set of behaviors with professional identity | Evading patient hood [52] Seeing self as a victim [52] | YES Behaviors incompatible with professional identity |