Qualitative Exploration of Barriers to Statin Adherence and Lipid Control

Abstract

Key Points Question What barriers to statin therapy adherence and control of cholesterol levels are revealed through qualitative interviews with participants in a randomized trial of financial incentives for adherence? Findings In this qualitative study of 54 participants, individuals whose cholesterol levels did not improve described a greater burden of chronic illness, were less frequently employed, were less focused on the risks of high cholesterol levels, appeared to have lower health literacy, were less engaged in their cholesterol level management, made fewer specific nutritional choices for optimizing health, and had greater difficulty obtaining healthy food compared with participants with marked improvement of cholesterol levels. Meaning These findings suggest that future interventions should consider addressing socioeconomic circumstances in combination with adherence interventions among patients needing to reduce cholesterol levels.

Effect of Financial Incentives for Process, Outcomes, or Both on Cholesterol Level Change

“…Taken together with other research on behavior change, these results suggest that effective interventions might need to combine financial incentives with other support, such as guidance and coaching, to help patients develop customized solutions to the particular obstacles they face. 20 , 27 , 41 , 42 …”

“…Taken together with other research on behavior change, these results suggest that effective interventions might need to combine financial incentives with other support, such as guidance and coaching, to help patients develop customized solutions to the particular obstacles they face. 20,27,41,42 Health insurance companies, government agencies, and most employers have deployed financial incentives to promote healthy behaviors. 43,44 Such programs have proliferated despite uncertainty about how to structure incentives effectively.…”

“…Recent advances in smart pill bottle technology have facilitated the measurement of medication adherence, 26 but their use may be difficult to integrate into a patient's routines. 27 In addition, incentives focused only on statin adherence might cause patients to neglect other important health behaviors, such as diet or exercise, or signal to patients that statins should take priority over other important medications, 28 causing unintended spillover effects on nontargeted health conditions. 29 Given these concerns, an intervention directly rewarding a surrogate health outcome, such as lowering low-density lipoprotein cholesterol (LDL-C) levels (an outcome incentive), could be appealing compared with daily adherence incentives.…”

Applying mixed methods to pilot feasibility studies to inform intervention trials

“…Qualitative data can be collected before, during, and after implementation of the intervention, and integrating the quantitative and qualitative data can help investigators understand not only whether an intervention works but also how and why or why not [ 22 , 36 ]. Common applications of mixed methods in randomized controlled trials (RCTs) involve embedding qualitative research to explore barriers and facilitators to study recruitment [ 38 , 39 ], intervention adherence [ 40 , 41 ], and study retention [ 42 , 43 ]. Qualitative research has also been used in RCTs to examine mechanisms [ 44 ] and contextual influences on interventions and outcomes [ 45 ].…”

Study design of BETTER-BP: Behavioral economics trial to enhance regulation of blood pressure

“…Results of several studies using a lottery incentive program (“regret lottery”) approach, whereby participants are encouraged to undertake healthy behaviors through the desire to avoid regret over losing financial incentives, have been promising [ 10 , 11 ]. However, other interventions tested have been negative [ [12] , [13] , [14] ] or effective only in limited subgroups [ 15 ]. Further, with few exceptions [ 16 ], whether these incentives translate to sustainable behavior change in vulnerable populations is unclear.…”