Abstract and Background
Background: Non-concordance with medication remains a major public health problem that imposes a considerable financial burden on the health care system, and there is still a need for studies on correlates of non-concordance. Our first aim is to analyse whether any of the individual characteristics age, educational level, financial strain, self-rated health, social participation, and trust in the health care system are associated with primary non-concordance with medication. Our second aim is to investigate whether people living in the same area have similar probability of primary non-concordance with medication, that relates to area social participation.
Methods: We analysed cross sectional data from 9 070 women and 6 795 men aged 18 to 79 years, living in 78 areas in central Sweden, who participated in the Life & Health year 2000 survey, with multilevel logistic regression (individuals at the first level and areas at the second level).
Results: Younger age, financial strain, low self-rated health, and low trust in the health care system were associated with primary non-concordance with medication. However, area social participation was not related to primary non-concordance, and the variation in primary non-concordance between the areas was small.
Conclusion: Our results indicate that people in central Sweden with younger age, financial difficulties, low self-rated health, and low trust in the health care system may have a higher probability of primary non-concordance with medication. However, the area of residence - as defined by administrative boundaries - seems to play a minor role for primary non-concordance.
Patients' concordance with medication is a prerequisite for effective drug therapy. Non-concordance is a major public health problem that imposes a considerable financial burden on the health care system.[1,2] Despite the comprehensive research on concordance during the last decades, non-concordance remains a concern in health care, and there is still a need for studies on correlates of non-concordance because the complex phenomenon of non-concordance is far from understood. It has been suggested that the social context in which non-concordance occurs should not be ignored,[1,2,4] and we have tried to incorporate this aspect in this study.
The term concordance implies agreement, trust, and harmony between patient and doctor regarding treatment, and acknowledges the patient as a decision maker, and a cornerstone is professional empathy.[2,5] The members of a working party of the Royal Pharmaceutical Society of Great Britain introduced the term concordance, which recognizes a patient's own choice to concord with treatment.
Patient non-concordance with medication may be divided into primary non-concordance, where the patient does not redeem the prescription, and secondary non-concordance, where the patient does not take the medication as prescribed.[2,6] Most studies have focused on secondary non-concordance.[7,8,9] Nevertheless, it is crucial to determine whether patients actually redeem their prescriptions from the pharmacy, because this is the first step in the complex phenomenon of concordance. Studies on primary non-concordance have reported non-redemption rates between 2% and 33%.[6,7,8,9,10,11,12,13,14,15,16] However, these studies vary greatly regarding assessment of primary non-concordance, participants, and setting.
Individual characteristics, such as age, educational level, self-rated health, and social support have been discussed as correlates of concordance, however, the results are inconsistent.[1,2,3,17,18] On the other hand, the influence of area factors, related to one's area of residence, have been scarcely investigated in relation to concordance. Yet, over and above individual characteristics, patients' concordance with medication might be related to the social context in which they live.[1,4] In a previous study, we observed that the association between social participation and concordance with antihypertensives varied among municipalities in Scania, Sweden (i.e., cross-level interaction), which suggests that the area of residence may influence the mechanisms behind the concordance behaviour.
Individual social participation describes how actively a person takes part in activities, groups, and associations, and social participation has been associated with health-related behaviours, such as smoking cessation and physical activity. Further, social participation is important for understanding the influence of social factors on health, and can be viewed as a feature of individual social networks. Social participation and social networks have been suggested to influence health behaviours, such as concordance with medication, possibly through information exchange and establishment of health-related group norms.[23,24] In our previous study in Scania, our results suggested an association between low social participation and low concordance with antihypertensives, and, therefore, we wanted to further investigate whether social participation, both at the individual and at the area level, was associated with general primary non-concordance with medication, in a different setting.
The area level of social participation has been considered as a structural component within the concept of social capital,[24,25] which describes social structures and social relationships in society. Living in an area with low social capital might decrease the individual probability of concordance with medication through mechanisms like poorer social networks, shared norms around health-related behaviour, transmission of health information, health care system factors, and social control over deviant health-related behaviour.[23,27] Previous studies have found associations between living in a disadvantaged area, with low social capital,[29,30] and use of medication. We were therefore interested in investigating whether social capital, as measured by the area level of social participation, might be related to primary non-concordance with medication.
Because of our contextual approach in this study, we used multilevel analysis, which handles information on both people and context simultaneously within the same model, and we investigated measures of variation as well as traditional measures of association.[32,33]
The first aim of this study is to analyse whether any of the individual characteristics age, educational level, financial strain, self-rated health, social participation, and trust in the health care system are associated with primary non-concordance with medication. The second aim is to investigate whether people living in the same area have similar probability of primary non-concordance with medication, that relates to area social participation.
BMC Public Health. 2006;6 © 2006 Johnell et al., licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cite this: Individual Characteristics, Area Social Participation, and Primary Non-concordance With Medication: A Multilevel Analysis - Medscape - Feb 01, 2006.