Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 15 nº 1 - Jan/Mar - 2018

Original Article Imprimir 

Páginas 42 a 49


Adherence to the medication regimen of adolescents undergoing liver transplant: motivational factors

Adhesión al régimen medicamentoso de los adolescentes sometidos a trasplante hepático: factores motivacionales

Adesão ao regime medicamentoso dos adolescentes submetidos a transplante hepático: fatores motivacionais

Autores: Susana Luísa Andrade Nogueira Lobo Carvalho1; Luís Manuel de Jesus Loureiro2; Maria de Lurdes Lopes de Freitas Lomba3

1. Master Medical Degree in Nursing from the Nursing School of Coimbra (ESEnfC). Coimbra, Portugal
2. PhD in Medicine from the University of Porto (U.Porto). Porto, Portugal. Adjunct Professor, Department of Mental and Psychiatric Health Nursing, School of Nursing Coimbra (ESEnfC). Coimbra, Portugal
3. Doctor in Nursing Sciences by the Institute of Biomedical Sciences of Abel Salazar (ICBAS), University of Porto (U.Porto). Porto, Portugal. Adjunct Professor, Department of Child Health and Pediatric Nursing, Coimbra College of Nursing (ESEnfC). Coimbra, Portugal

Correspondência:
Maria de Lurdes Lopes de Freitas Lomba
Rua Quinta da Portela, n. 91, 2.esq
Coimbra, Portugal. CEP: 3030-481
(mlomba@esenfc.pt)

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Keywords: Liver transplantat, adolescent, medication adherence, motivation.
Palabra Clave: Trasplante de hígado, adolescente, adhesión a la medicación, motivación.
Descritores: Transplante de fígado, adolescente, adesão à medicação, motivação.

Abstract:
OBJECTIVE: Characterize adolescents undergoing liver transplantat, verify their adherence to the medication regimen, their adherence motivation succeed in the regime and if they felt competent to adherence.
METHODS: Cross-sectional study with 32 adolescents. A questionnaire was used for data collection that included the Measure Treatment Adherence scale (MAT), immunosuppression blood values, Treatment Self-Regulation Questionnaire (TSRQ) and Perceived Competence Scale (PCS), these last two were translated to Portuguese.
RESULTS: The MAT scores were: minimum 5.29, maximum 6.00, (100% of the adolescents reported to adhering the treatment). Of the mean blood levels of tacrolimus, 66,7% were within therapeutic ranges. Adolescents showed a predominantly autonomous and high motivation to fulfill the medication prescription (TSRQ autonomous motivation subscale presents an average value of 6.5, in a range from 1 to 7) and showed self-confidence and believing in their capacity to follow the medication regimen, due to the high competence perceived (PCS presents an average value of 6.65, ranging from 1 to 7). Motivation and perceived competence were not related to adherence (rs=.119 p=.523; rs=.283 p=.123, respectively). Perceived competence and autonomous motivation have a positive, moderate and statistically significant correlation (rs=.482 p=.006).
CONCLUSION: It may be said that medication adherence when evaluated subjectively scores higher compared to the blood values of immunosuppression. Also, motivation and perceived competence do not seem to influence the adherence to the medication regimen. It is necessary the development of more multi-center study based on solid theory to examine adherence behavior more.

Resumen:
OBJETIVO: Caracterizar a los adolescentes con trasplante hepático; verificar su adhesión al régimen medicamentoso; su motivación para cumplirlo y si se consideran aptos a esa adhesión.
MÉTODOS: Estudio descriptivo transversal con 32 adolescentes. El instrumento usado fue un cuestionario autorrellenado que incluía la escala Medida de Adhesión a los Tratamientos (MAT), los valores sanguíneos de inmunosupresión, el Treatment Self-Regulation Questionnaire (TSRQ) y la Perceived Competence Scale (PCs), estos dos traducidos al idioma portugués.
RESULTADOS: Los scores de la MAT fueron: mínimo 5,29, máximo 6,00 (100% de los adolescentes relataron que adhirieron al tratamiento). De los niveles sanguíneos medios de tacrolimus, 66,7% estaban dentro de intervalos terapéuticos. Los adolescentes demostraron una motivación predominantemente autónoma y alta para cumplir la prescripción medicamentosa (subescala motivación autónoma de TSRQ presenta valor medio 6,5 enun intervalo de 1 a 7) y se mostraron con confianza y seguros en su capacidad para cumplir el régimen medicamentoso, dada la alta capacidad percibida (PCs presenta un valor medio 6,65 enun intervalo de 1 la 7). La motivación y lacapacidadpercibida no estaban relacionadas con la adhesión al régimen medicamentoso (Rs=.119 p=.523; Rs=.283 p=.123, respetivamente). La capacidad percibida y la motivación autónoma tienen una correlación positiva, moderada y estadísticamente significativa (Rs=.482 p=.006).
CONCLUSIÓN: La adhesión medicamentosa, cuando evaluada subjetivamente, obtuvo mayor puntuación con relación a los valores sanguíneos de inmunosupresión. Además, motivación y capacidad percibida no parecen influenciar en la adhesión al régimen medicamentoso. Es necesario el desarrollo de mayores estudios multicéntricos con base en una teoría sólida para examinar mejorel comportamiento de adhesión.

Resumo:
OBJETIVO: Caracterizar os adolescentes com transplante hepático; verificar a sua adesão ao regime medicamentoso; a sua motivação para cumpri-lo e consideram-se aptos a essa adesão.
MÉTODOS: Estudo descritivo transversal com 32 adolescentes. O instrumento usado foi um questionário autopreenchido que incluía a escala Medida de Adesão aos Tratamentos (MAT), os valores sanguíneos da imunossupressão, o Treatment Self-Regulation Questionnaire (TSRQ) e a Perceived Competence Scale (PCS), estes dois traduzidos para a língua portuguesa.
RESULTADOS: Os escores da MAT foram: mínimo 5,29, máximo 6,00 (100% dos adolescentes relataram que aderiram ao tratamento). Dos níveis sanguíneos médios de tacrolímus, 66,7% estavam dentro de intervalos terapêuticos. Os adolescentes demonstraram uma motivação predominantemente autônoma e elevada para cumprir a prescrição medicamentosa (subescala motivação autônoma do TSRQ apresenta valor médio 6,5 em um intervalo de 1 a 7) e mostraram-se confiantes e crentes na sua capacidade para cumprir o regime medicamentoso, dada a elevada competência percebida (PCS apresenta um valor médio 6,65 em um intervalo de 1 a 7). A motivação e a competência percebida não estavam relacionadas com a adesão ao regime medicamentoso (rs=.119 p=.523; rs=.283 p=.123, respetivamente). A competência percebida e a motivação autônoma têm uma correlação positiva, moderada e estatisticamente significativa (rs=.482 p=.006).
CONCLUSÃO: A adesão medicamentosa quando avaliada subjetivamente obteve maior pontuação em relação aos valores sanguíneos de imunossupressão. Além disso, motivação e competência percebida não parecem influenciar a adesão ao regime medicamentoso. É necessário o desenvolvimentos de maiores estudos multicêntricos com base numa teoria sólida para examinar melhor o comportamento de adesão.

INTRODUCTION

People undergoing liver transplantation need to adhere to a set of medical recommendations, in particular to immunosuppressive therapy. Immunosuppressant is fundamental for the success of transplantation, avoiding complications such as acute rejection, chronic rejection with graft loss, a new transplantation, and even death1,2.

Adolescence is a period characterized by the often difficult physical, emotional and cognitive changes of the adolescent balance with the behaviors required for optimal therapeutic adherence3,4. Adolescent concerns about body image, definition of social function, issues related to peers, and their struggle with self-esteem can be exacerbated by the development of a chronic condition in which complex and prolonged therapeutic regimes generate revolt against the control that the regime has over their lives, and may lead to non-adherence therapeutics5,6.

There are no insight measures to assess adherence behavior because both objective and subjective strategies have advantages and disadvantages. An assessment using different methods becomes more sensitive than using only a single measure.5. Therapeutic adherence is a multidimensional phenomenon influenced by several factors among which the patient's motivation to adhere to treatment5.

The theory of self-determination (TAD) is a general theory of human motivation that defines distinct types of motivation: autonomous motivation (doing something for the personal good), controlled motivation (doing something for an instrumental reason), and motivation something unintentional)7. Emphasis is placed on the importance of the will and the choice to initiate behavior to the detriment of control, manipulation and coercion8. It is emphasized that the satisfaction of the needs of autonomy, competence and relationship are fundamental for the processes of internalization and integration, through which a person comes to self-regulate and sustain health and well-being behavior9,10. This theory reveals that autonomic motivation and perceived competence are important in initiating and maintaining changes in health behaviors10.

In order to promote adherence to the drug regimen, it is necessary to resort to structured, studied and proven effective interventions11. Educational interventions with an emphasis on the attitudes of adolescents to their disease and their management present more benefits than interventions focused on knowledge acquisition. Behavioral interventions should be carried out with the objective of increasing the perceived importance of adherence and reinforcing confidence through the construction of self-management competences, based on the intrinsic motivation of the patient5. A single approach isn´t effective and a multidisciplinary approach should be used6.

Although the characteristics of adolescent development may influence the behavior of non adherence to the drug regimen, literature on the subject is scarce. The recognition of the prevalence and consequences of non-adherence makes it evident that it is essential to identify the non-adherent adolescent with the intention of promoting adherence to the drug regimen. Thus, it is fundamental to carry out studies on adherence to the drug regimen in this population.

In view of the above evidence, the present study intends to characterize a sample of adolescents with liver transplantation, to verify their adherence to the drug regimen, their motivation to comply with it and if they consider themselves competent for adherence.


METHOD

This is a cross-sectional descriptive study conducted at the Hospital and University Center of Coimbra, in the city of Coimbra, Portugal, where the sample was selected in a non-probabilistic manner for convenience, consisting of 32 adolescents who meet the predefined criteria: age between the ages of 10 and 19; submitted to liver transplantation; followed in a tertiary hospital; with command of the Portuguese language (as well as their parents); and who agreed to participate voluntarily in the research and authorized in writing after framing the study and objectives. They were guaranteed the confidentiality of the data, where, the data collection was made based on planned instruments, in the period between July 2015 and May 2016.

Adherence to the medication was evaluated using the Treatment Adherence Measure (MAT) that evaluates the behavior of the individual in relation to the daily use of medications. The score obtained is the mean of the response to the seven items, where the values 5 and 6 correspond to the adolescent's score, and the remainder are considered non-adherent12. Another method used to evaluate therapeutic adherence was the mean value of the three tacrolimus blood levels, obtained within one year before the questionnaire was filled in, considering the therapeutic values used in the study service.

The Treatment Self-Regulation Questionnaire (TSRQ) was used to evaluate autonomic motivation, controlled motivation and amotivation to meet the drug regimen. Each adolescent is assigned a score in each subscale, given by the average of the responses to the items that make up each subscale. The subscale with the highest value is representative of the type of motivation of the adolescent.

The perceived competence to comply with the drug regimen was assessed through the Perceived Competence Scale (PCS) which assesses the person's degree of confidence in achieving health behaviors. The score results from the average of the answers to four items. The TSRQ and PCS related to the drug regimen were translated into Portuguese.

The data collected were subjected to statistical treatment using the statistical software Statistical Package for the Social Sciences (SPSS), version 24. The data analysis was performed through descriptive statistics to describe the characteristics of the sample and to find answers to the research questions and inferential analyzes to verify hypotheses.

This project was approved by the Ethics Committee of the Research Unit in Health Sciences: Nursing of the Nursing School of Coimbra, by the Innovation and Development Unit of the Hospital and University Center of Coimbra (CHUC), and a favorable opinion was obtained CHUC Ethics Committee for Health and authorization of the CHUC Board of Directors.


RESULTS

The 32 adolescents that constituted the sample had a mean age of 14.44 years, ranging from 10 to 19 years, where there is a predominance of male adolescents (Table 1).




It was verified that 46.9% of adolescents live in cities, 34.4% in rural areas and 18.8% of adolescents live in villages. Regarding the educational level, 28.1% of the adolescents attend the 5th and 6th years of schooling, 37.5% are in the 7th, 8th or 9th year of schooling and in the 10th, 11th and 12th year of schooling they are 34.4%.

When the adolescents' behavior regarding medication adherence was evaluated, MAT scores (Table 2) ranged from 5.29 to 6, with an average value of 5.75, considering the interval from 1 to 6. It should be noted that The values between 5 and 6 correspond to adolescents considered adherent and the rest are considered non-adherent. Thus, it can be considered that all participants are adherent to the medication.




Adherence to medication, measured through the mean blood levels of tacrolimus obtained in the year prior to completing the questionnaire (table 3), revealed that 66.7% of the adolescents were within therapeutic intervals.




The results of the TSRQ subscale scores (Table 4) revealed that the autonomic motivation presents an average value of 6.5, which is the highest in comparison to the motivation to comply with the prescription of adolescents undergoing liver transplantation. Motivation had an average value of 4.5; the motivation had an average value of 3.4, the lowest of the three subscales. Controlled motivation and motivation have very different average values ranging from 1 to 7.




Table 4 also shows that the perceived competence of adolescents regarding compliance with prescription drugs has an average value of 6.65 (between 1 and 7), according to the results of the PCS scale. The values are not very diverse ranging from 5 to 7.

Later, when exploring the relationship between the variables "adherence to the drug regimen" and "motivation", using the non-parametric Spearman Ró Correlation test, it was verified that adherence to the drug regimen doesn´t correlate with autonomous motivation (rs = , 119 p =, 523), with controlled motivation (rs = -, 200 p =, 273), nor with motivation (rs = -, 216 p =, 261). The results also show that the perceived competence doesn´t correlate in a statistically significant way with the adherence to the drug regimen (rs =, 283 p =, 123). Regarding the variables autonomous motivation and perceived competence, it is verified that they present a positive, moderate and statistically significant correlation (rs = 0.486, p = 0.006).


DISCUSSION

As all adolescents are adherent according to the results obtained by MAT it was expected that the values of immunosuppressant would reflect higher values of therapeutic adherence, which nevertheless demonstrate a 66.7% adhesion. However, it should be noted that questionnaires that assess behaviors related to specific medical recommendations may be better predictors of adherence behavior than questionnaires that assess the patient's overall characteristics or personality traits 5. In any case, MAT remains a subjective strategy for assessing adherence behavior and as such, these results may be due to a distorted perception of the adolescent himself about his behavior, in which the importance of strict adherence to the therapeutic regimen doesn´t is valued. Adolescents sometimes responded to questionnaires with their parents, which may have also influenced their responses. On the other hand, it should also be remembered that although the blood levels of a drug are an objective measure, they may vary with personal pharmacokinetics and absorption13.

The values obtained in this study regarding blood levels are very close to those obtained in other international studies14,3 made with adolescents undergoing liver transplantation, although with different dimensions of the present study. This similarity reinforces the idea that adolescence is a period of high risk, particularly for non-adherence to therapeutic regimes and in different cultures. Therefore, non-adherence to the immunosuppressive regimen by adolescents should be valued by health professionals, given its importance for graft and adolescent survival.

In this study, the results reveal that adolescents undergoing liver transplantation predominantly present autonomic motivation to comply with the prescription, since this variable assumes a high value. On the other hand, these adolescents feel confident and believe in their ability to comply with the drug regimen, considering that perceived competence also has a high average value. However, there was no relationship between motivation and drug adherence, or between perceived competence and adherence.

The scarce number of studies that evaluate the motivation of adolescents with chronic disease to adhere to the drug regimen make it difficult to compare the results. It is worth noting the work of Garret15, who, using a sample similar to the present study, found similar results in that both didn´t correlate autonomic motivation with adherence to the drug regimen. Similar values were found regarding the autonomous motivation of the present study and other health behaviors such as glycemic control16, smoking cessation17 and physical activity18. However, these studies positively correlate the autonomous motivation and positive results related to health behaviors. That is, they concluded that the greater the autonomous motivation, the greater is the adherence to a health behavior with positive results, confirming the assumptions of the TAD.

Regarding perceived competence, the values of this study are significantly higher than those of another study conducted with a sample of similar age group15. Given that studies evaluating perceived competence in adolescents with chronic disease are scarce, the results of the present study were compared with other studies conducted in adults, which assess the perceived competence using PCS in health behaviors. Thus, studies using PCS relating to TAD with glycemic control16 and with smoking cessation17 show similar values, but lower compared to the present study. Nevertheless, they revealed positive results in the health behaviors, being able to infer that the present study doesn´t go against the assumptions of the TAD nor to the studies developed in light of this theory in that it doesn´t allow to infer that the autonomous motivation and the high perceived competence are associated with better results in the adoption of health behaviors.

The results obtained in the present study show that the higher the autonomic motivation for adherence to the drug regimen, the higher the level of perceived competence. In fact, recent scientific evidence resulting from the application of ADT in health behaviors suggests that perceived competence is facilitated by autonomous motivation, since individuals with a high will to act are more likely to learn new knowledge and apply new strategies that result perceived competence. This theoretical conjecture, coupled with recent empirical evidence based on ADR for health behaviors, proposes that authentic perceived competence doesn´t arise without the individual feeling autonomously motivated19. According to the TAD, autonomic motivation and perceived competence are important for initiating and maintaining changes in health behavior10.

Several studies suggest that autonomic motivation and perceived competence are predictive factors for the alteration and maintenance of behaviors relevant to health. Autonomous motivation and perceived competence to comply with the drug regimen therefore seem to play a key role in health behavior and outcomes.


CONCLUSION

Adolescence is a period of high risk for non-adherence to the drug regimen. The behavior of adolescents submitted to liver transplantation in relation to the daily use of drugs, when evaluated subjectively, reveals a greater adherence to the drug regimen compared to the result of immunosuppressive blood values. Therefore, an evaluation using different methods becomes more sensitive than using only a single measure.

These adolescents undergoing liver transplantation have a predominantly autonomous motivation to comply with prescription drugs, and feel confident and believe in their ability to comply with the drug regimen.

Perceived motivation and competence don´t seem to influence drug adherence. Autonomous motivation, on the other hand, presents a positive, moderate and statistically significant correlation with the perceived competence. That is, the higher the autonomous motivation for adherence to the drug regimen, the higher the level of competence perceived in these adolescents, as postulated by TAD. Autonomous motivation and the perceived competence to comply with the drug regimen seem to play a fundamental role in health behavior and outcomes. Therefore, health professionals must include in the planning of their interventions strategies that can support these needs. However, more multicenter studies will be needed based on a solid theory to better examine adherence behavior.

The contributions of this research allow us to suggest some considerations for future research, in which we highlight studies that evaluate the influence of motivation in therapeutic adherence using the instruments submitted to the translation and validation process, in order to continue the development of the thematic in Portugal, given the shortage of published studies.

The results also led to recommendations for interventions for this population, planned and performed by health professionals in order to promote adherence to the drug regimen and thus demonstrate the applicability of the study in health care contexts. We consider that health professionals, when planning the intervention program that promotes drug adherence, should: consider the changes that occur during adolescence; to identify the risk factors associated with noncompliance and the noncompliance complications in the study population, in order to know the impact of the non-adherence behavior to the immunosuppressive regimen; provide the satisfaction of the innate psychological needs - competence, autonomy and relationship.

Among the recommendations for the practice of care, it is necessary to make available to all adolescents submitted to transplantation a specific program of information and education, with the objective of increasing adherence to the drug regimen and favoring a better quality of life. This program should be developed by a multidisciplinary team that uses a multidisciplinary strategy that includes educational and behavioral interventions.


NOTE

This work was part of the Dissertation presented to the Nursing School of Coimbra to obtain a Master's degree in Child Health Nursing and Pediatrics. Data collection for the study: Pediatric Transplantation Unit of the Pediatric Hospital of the Hospital and University Center of Coimbra, Portugal.


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