Interventions Incorporating Therapeutic Alliance to Improve Medication Adherence in Black Patients with Diabetes, Hypertension and Kidney Disease: A Systematic Review

Abstract

Background: Black Americans have a disproportionately increased risk of diabetes, hypertension, and kidney disease, and higher associated morbidity, mortality, and hospitalization rates than their White peers. Structural racism amplifies these disparities, and negatively impacts self-care including medication adherence, critical to chronic disease management. Systematic evidence of successful interventions to improve medication adherence in Black patients with diabetes, hypertension, and kidney disease is lacking. Knowledge of the impact of therapeutic alliance, ie, the unique relationship between patients and providers, which optimizes outcomes especially for minority populations, is unclear. The role and application of behavioral theories in successful development of medication adherence interventions specific to this context also remains unclear. Objective: To evaluate the existing evidence on the salience of a therapeutic alliance in effective interventions to improve medication adherence in Black patients with diabetes, hypertension, or kidney disease. Data Sources: Medline (via PubMed), EMBASE (OvidSP), Cumulative Index of Nursing and Allied Health Literature (CINAHL) (EBSCOhost), and PsycINFO (ProQuest) databases. Review Methods: Only randomized clinical trials and pre/post intervention studies published in English between 2009 and 2022 with a proportion of Black patients greater than 25% were included. Narrative synthesis was done. Results: Eleven intervention studies met the study criteria and eight of those studies had all-Black samples. Medication adherence outcome measures were heterogenous. Five out of six studies which effectively improved medication adherence, incorporated therapeutic alliance. Seven studies informed by behavioral theories led to significant improvement in medication adherence. Discussion/Conclusion: Study findings suggest that therapeutic alliance-based interventions are effective in improving medication adherence in Black patients with diabetes and hypertension. Further research to test the efficacy of therapeutic alliance-based interventions to improve medication adherence in Black patients should ideally incorporate cultural adaptation, theoretical framework, face-to-face delivery mode, and convenient locations.

Hypertension management in chronic kidney disease

“…Behavioral interventions are pivotal in promoting adherence by addressing psychological factors and acknowledging any social determinants of health that infl uence medication-taking behaviors. 24 Behavioral techniques such as motivational interviewing can be employed to explore patients' beliefs, concerns, and barriers related to medication adherence. 24 This patient-centered approach allows healthcare providers to better understand the individual patient's perspective and tailor interventions to them accordingly.…”

“…24 Behavioral techniques such as motivational interviewing can be employed to explore patients' beliefs, concerns, and barriers related to medication adherence. 24 This patient-centered approach allows healthcare providers to better understand the individual patient's perspective and tailor interventions to them accordingly. Addressing misconceptions or fears related to medications and collaboratively resolving practical problems, such as the cost or complexity of medication regimens, can signifi cantly improve adherence.…”

“…Enhancing medication adherence is a critical component of effective HTN management in patients with CKD. Behavioral interventions are pivotal in promoting adherence by addressing psychological factors and acknowledging any social determinants of health that influence medication-taking behaviors 24…”

“…Behavioral techniques such as motivational interviewing can be employed to explore patients' beliefs, concerns, and barriers related to medication adherence 24. This patient-centered approach allows healthcare providers to better understand the individual patient's perspective and tailor interventions to them accordingly.…”

“…Social support systems also play a crucial role in medication adherence. Involving family members or caregivers in the patient's care can provide additional motivation and accountability 24. Encouraging patients to discuss their medication regimen and adherence challenges with their support network can foster understanding and a collaborative approach to improving adherence.…”