Schizophrenia Medication Adherence among Patients

PICOT Question: Is the use of SMS reminders and notifications more effective than standard therapy in reducing the occurrence of medication non-adherence among patients with schizophrenia?

Similarities and Differences of the Reviewed Studies

This section compares the studies based on five key areas: participants and target population, study designs, study variables, research methods, and study findings.

Study Participants and Target Population

The reviewed studies differed in their target populations and study sites. One of the studies (Xu et al., 2019) was conducted on patients with schizophrenia while two (Chiaranai et al., 2023; Belete et al., 2023) focused on patients with type II diabetes mellitus. Two other studies targeted patients with coronary heart disease (Zhao et al., 2019; Park et al., 2020), while one study investigated individuals on antiretroviral therapy (Sherman et al., 2018). The study setting also differed across all six studies. Xu et al. (2019) was based in nine villages in Wuhan, China, while Zhao et al. (2019) was a systematic review and meta-analysis synthesizing data from trials carried out in five countries, including two developing countries. Belete et al. (2023) brought together data from trials carried out in eight countries, including South Africa, Egypt, France, Indonesia, USA, Japan, India, and the Netherlands. One of the studies was based in Thailand, while the other two were based in California and Florida in the US.

Study Design and Data Collection Methods

Two of the studies (Sherman et al., 2018; Park et al, 2020) were qualitative inquiries, while four were quantitative studies. Both qualitative studies made use of primary data, with one using focus group discussions and the other using face-to-face structured interviews to collect data. Two of the quantitative studies (Chiaranai et al., 2023; Xu et al., 2019) were randomized controlled trials with a case-control approach, while two (Zhao et el., 2019; Belete et al., 2023) were systematic reviews and meta analyses of randomized controlled trials. The two randomized controlled trials used primary methods of data collection, including administration of adherence surveys and observation techniques to gather research data.

Study Variables and their Measurement

The primary similarity is that all six studies had medication adherence as the outcome variable and text message reminders/standard care as the independent variable. However, differences lie in the way the studies measure medication adherence. Further, some of the studies have multiple outcome variables. Two of the quantitative studies investigated the impact of text message reminders /alerts on medication adherence and patients’ clinical outcomes (Zhao et al., 2019; Xu et al., 2019), while one (Chiaranai et al., 2023) investigated the effect of texts on medication adherence and quality of life. Only one study investigated the effect of text message reminders solely on medication adherence among study participants (Belete et al., 2023). The qualitative studies both sought to understand participants’ experiences and attitudes on the use of text message reminders as a strategy for improving medication adherence.

There were significant differences in the way medication adherence was measured across the quantitative studies. Xu et al. (2019) measured medication adherence among schizophrenic patients using both observation (unannounced pill counts to compare pill numbers to refill records) and adherence rating scales, specifically the Drug Attitude Inventory and the Brief Adherence Rating Scale. Chiaranai et al. (2023) measured medication adherence among type II diabetes mellitus patients by observing their levels of glycated hemoglobin as documented in patient records. Both Zhao et al. (2019) and Belete et al. (2023) measured medication adherence by merging data collected from RCTs that employed adherence rating survey scales, including the Self-Efficacy for Appropriate Medication Use Scale, Management of Disease Scale, and the Morisky Medication Adherence Scale.

Study Findings

All six studies found that text message reminders significantly improved medication adherence among study participants, although the effect on clinical outcomes was varied. Xu et al. (2019) found that the use of text message reminders improved medication adherence rates among schizophrenic patients by 27 percent, although the effect on patient symptoms was not statistically significant. On their part, Zhao et al. (2019) found that medication adherence rates among coronary heart disease patients exposed to text message alerts and reminders was 2.9 times higher than that of control group participants. Clinical outcomes (as measured by cholesterol levels and systolic blood pressure) also improved with the use of reminders. Similarly, Chiaranai et al. (2023) found that the use of text message reminders reduced patient glycated hemoglobin levels from 7.86 to 6.5 HbA1c in the intervention group, while levels increased from 7.829 to 7.853 in the control group. The study also found that reminders had a significant positive effect on quality of life. Belete et al. (2023) found that text message reminders improved medication adherence among type II diabetes patients from 14 percent to 59 percent. Both Sherman et al. (2018) and Park et al. (2020), in their qualitative studies, found that the use of text message reminders enhanced adherence to coronary heart disease medication and antiretroviral drugs, although there was a need to ensure the texts protected patients’ confidentiality and that patients have greater control over their timing and content.

Practical or Clinical Significance of Study Findings to Nursing Practice

The findings of the reviewed studies have fundamental implications for nursing practice. During times of pandemic or when healthcare resources are overstretched and it is necessary to deliver care in contactless and remote ways, the use of mobile phone text message reminders would provide a plausible solution to enhance medication adherence among patients. The use of text reminders/alerts may be more appropriate than other digital interventions such as mobile apps due to the accessibility and affordability of mobile phones among the general population (Belete et al., 2023). Most adults, even low-income earners, own a mobile phone, making short message interventions an appropriate approach for reducing barriers related to access such as lack of finances, medical consultation fees, and transport limitations, all of which may limit medication adherence.

It may be important for nursing professionals to ensure that text message reminders are structured in line with the target population’s needs and context (Belete et al, 2023). For instance, Sherman et al. (2018) found that text message reminders are likely to change adherence behavior if patients are allowed to exercise control over the timing and frequency of such messages. Failure to adapt the texts to meet patients’ needs may lead to agitation, reducing their effectiveness. It is also prudent that text messages are structured in a manner that protects patients’ confidentiality. For instance, reminder texts should do not reveal the patient’s illness, to safeguard them in case third parties read the text (Sherman et al., 2018).

For patients with schizophrenia and other mental illnesses, studies have shown that family support has a significant influence on adherence (Rindayati et al, 2021). Thus, text messaging interventions could be combined with family-based interventions to be more effective for these populations. For instance, text message reminders could be sent out to both patients and their caregivers rather than to patients alone to effectively improve adherence. At the same time, text messages could be combined with regular educational interventions targeting caregivers to ensure they understand the importance of adhering to antipsychotic medication (Rindayati et al., 2021).

Answer to the PICOT Question

The reviewed studies found that text message reminders had a significant positive effect on medication adherence among different patient populations, including patients with schizophrenia. Thus, this text concludes that the use of SMS reminders and notifications is more effective than standard therapy in reducing the occurrence of medication non-adherence among patients with schizophrenia. Further research may be necessary to assess the effect of such reminders on schizophrenic patients’ clinical outcomes, as well as the effects of timing and frequency of reminder messages on medication adherence.