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Barriers to and Facilitators of Infertility Medication Adherence

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Barriers to and Facilitators of Infertility Medication Adherence BARRIERS TO AND FACILITATORS OF INFERTILITY MEDICATION ADHERENCE: A MIXED METHODS STUDY A DISSERTATION IN Nursing Presented to the Faculty of the University of Missouri-Kansas City in partial fulfillment of the requirements for the degree DOCTOR OF PHILOSOPHY by DIANE MAHONEY B.S.N., University of Kansas, 1995 M.S.N., University of Kansas, 2000 D.N.P., University of Missouri-Kansas City, 2011 Kansas City, Missouri 2019 BARRIERS TO AND FACILITATORS OF INFERTILITY MEDICATION ADHERENCE: A MIXED METHODS STUDY Diane Mahoney, Candidate for the Doctor of Philosophy Degree University of Missouri-Kansas City, 2019 ABSTRACT Background. Infertility treatment protocols require women to engage in self- management of their prescribed medication regimens, yet adherence to infertility medication schedules have been suboptimal. No prior research has investigated barriers to and facilitators of infertility medication adherence (MA) that could assist in the development of effective interventions to overcome medication non-adherence (MNA). Purpose. The purpose of this study was to assess barriers to and facilitators of infertility MA among women undergoing infertility treatment. This study was approved by the University of Missouri-Kansas City Institutional Review Board (IRB) and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Setting. The study setting was a reproductive medicine and infertility clinical practice serving women who reside in urban, suburban, and rural communities. Methods. Supported by Ajzen and Fishbein’s Reasoned Action Model, a convergent mixed methods design was conducted to correlate women’s perceived barriers to and facilitators of infertility MA. Women in a convenience sample were interviewed and completed questionnaires at study onset followed by one to two subsequent months of iii electronically monitored medication-taking using the Medication Event Management System® (MEMS). Results. The total sample consisted of 30 participants, of which 18 (60%) participants used the MEMS® with infertility medication-taking. The overall median infertility adherence MA score was 0.98 with a range of .75 to 1.00. The median adherence score of women who were considered non-adherent (n=9) was 0.90, and those who were considered adherent (n=9) was 1.00. MA scores significantly (r = -.49, p= 0.020) increased when the total MA barrier scores decreased. Women with a higher MA total barrier scores had significantly (p= 0.019) lower MA scores compared to women with lower total barrier scores. Women who were adherent to their infertility medication regimen had a significantly (p= 0.009) higher probability to report a positive view on treatment success compared to women who were not adherent. Women who lived in urban and rural communities had a significantly (p= 0.010) higher probability to report a positive view regarding treatment success compared to women who lived in suburban communities. Caucasian and African- American women had a significantly (p= 0.049) higher probability to report feelings of self- blame for experiencing infertility compared to Asian, Hispanic, and Native American women. Women who had experienced two to three prior failed treatment cycles had a significantly (p= 0.047) higher probability to report feelings of emotional distress compared to women who had experienced zero to one prior failed cycle. Women with children had a significantly (p= 0.015) lower probability to report having a supportive partner compared to women who were childless. There were no significant relationships found between the reported MA facilitators and infertility MA scores. iv Conclusion. These study findings offer new insight about this unique population that could impact the future of clinical practice. This study serves as a framework to foster ongoing scientific discovery including new interventional studies aimed at optimizing infertility MA. v APPROVAL PAGE The faculty listed below, appointed by the Dean of the School of Nursing and Health Studies, have examined a dissertation titled “Barriers to and Facilitators of Infertility Medication Adherence: A Mixed Methods Study,” presented by Diane Mahoney, candidate for the Doctor of Philosophy degree and hereby certify that in their opinion it is worthy of acceptance. Supervisory Committee Cynthia L. Russell, Ph.D., RN, FAAN, Committee Chair UMKC School of Nursing and Health Studies Maryann Bozzette, Ph.D., RN University of Missouri - St. Louis College of Nursing Eduardo Abreu, M.D., DEng UMKC School of Nursing and Health Studies Sangbeak Ye, Ph.D. UMKC School of Nursing and Health Studies An-Lin Cheng, Ph.D. UMKC School of Medicine vi CONTENTS ABSTRACT ...................................................................................................................... iii LIST OF ILLUSTRATIONS .............................................................................................. xi LIST OF TABLES .............................................................................................................xii ACKNOWLEDGEMENTS .............................................................................................. xiv Chapter 1. INTRODUCTION ................................................................................................... 1 Study Purpose and Working Hypothesis ..................................................... 3 Specific Aims, Research Questions, and Hypotheses ................................. 4 Primary Aim/Research Question ..................................................... 4 Secondary Aim/Research Question ................................................. 4 2. REVIEW OF LITERATURE .................................................................................. 6 Abstract ........................................................................................................ 6 Introduction.................................................................................................. 7 Methods ..................................................................................................... 11 Literature Search Strategy ............................................................. 11 Inclusion/Exclusion Criteria .......................................................... 11 Data Extraction .............................................................................. 12 Quality Assessment ....................................................................... 13 Results........................................................................................................ 13 Characteristics of Study Participants ............................................. 28 Study Location and Practice Setting .............................................. 28 Study Purpose and Study Type ...................................................... 28 vii Medication Adherence and Theoretical Framework ..................... 29 Predictors and Barriers Related to Medication Adherence ...................................................................................... 29 Discussion .................................................................................................. 34 Strengths and Limitations ............................................................. 34 Implications from the Findings ..................................................... 35 Recommendations for Future Research ........................................ 35 Conclusion ................................................................................................ 35 3. THEORECTICAL FRAMEWORK AND METHODOLOGY ............................ 37 Theoretical Framework ............................................................................. 37 Fishbein and Ajzen’s Reasoned Action Model ........................................ 37 Evolution of the Reasoned Action Model .................................... 38 Present Reasoned Action Model ................................................... 39 Methodology ............................................................................................. 41 Research Design ........................................................................... 41 Participants ................................................................................... 42 Setting ........................................................................................... 45 Conceptual Definitions ................................................................. 46 Instruments ................................................................................... 46 Procedure ...................................................................................... 50 Risk Reduction .......................................................................................... 54 Data Management ..................................................................................... 55 Data Analysis ............................................................................................ 55 viii 4. RESULTS ..................................................................................................................... 59 Recruitment and Enrollment ................................................................................. 59 Patient Characteristics .......................................................................................... 60 Primary Research Question .................................................................................. 63 Hypothesis 1 ............................................................................................
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