HISPANIC MEDICATION ADHERENCE STUDY
TABLE OF CONTENTS
EXECUTIVE SUMMARY........................................................................................................................................................................................... 2
INTRODUCTION....................................................................................................................................................................................................... 4
STUDY OBJECTIVES............................................................................................................................................................................................... 4
STUDY DESIGN AND METHODOLOGIES.............................................................................................................................................................. 5
PROVIDER KEY INFORMANT INTERVIEW RESULTS........................................................................................................................................... 6
Insights from the Key Informants.......................................................................................................................................................................... 7
SURVEY RESULTS................................................................................................................................................................................................. 10
When you don’t take your medication, what is the main reason you don’t take it?........................................................................................ 17
Affordability..................................................................................................................................................................................................... 17
Ways to Improve Medication Adherence........................................................................................................................................................ 17
What helps you remember your medication?................................................................................................................................................. 18
What would help Hispanics take their medication?........................................................................................................................................ 19
SUMMARY AND RECOMMENDATIONS................................................................................................................................................................ 20
Some of the key findings we can draw from our research are the following....................................................................................................... 20
Recommendations.......................................................................................................................................................................................... 21
Action items.................................................................................................................................................................................................... 21
ABOUT THE AUTHORS.......................................................................................................................................................................................... 22
About HolaDoctor................................................................................................................................................................................................ 22
About EnvisionRx................................................................................................................................................................................................ 22
About the Authors................................................................................................................................................................................................ 22
CONTACTS............................................................................................................................................................................................................. 23
EXHIBIT 1: HISPANIC MEDICATION ADHERENCE STUDY – COMPLETE RESPONSES TO ALL QUESTIONS............................................... 24
Section A: Total Responses................................................................................................................................................................................ 24
Section B: Demographics.................................................................................................................................................................................... 24
Section C: Medical History.................................................................................................................................................................................. 28
Section D: MMAS................................................................................................................................................................................................ 30
Section E: Initial Prescription.............................................................................................................................................................................. 32
Section F: Fulfillment........................................................................................................................................................................................... 35
Section G: Adherence......................................................................................................................................................................................... 36
REFERENCES........................................................................................................................................................................................................ 39
HISPANIC MEDICATION ADHERENCE | 1
EXECUTIVE SUMMARY
Introduction: Hispanics are the largest and one of the fastest-growing minority groups in the United States. Hispanics have
higher rates of certain medical conditions, e.g., diabetes, than non-Hispanic whites. For nearly all conditions, Hispanics have
lower medication adherence than non-Hispanic whites. A limited number of interventions have been tested to increase medication
compliance among Hispanics, but there is still very poor understanding of why Hispanics do not fill and/or adhere to their
medication condition management protocols.
Objectives: The overall objective of the study was to increase our understanding of how this increasingly dominant demographic
group use and adhere to medication protocols. Specific objectives were to: (1) Gain a better understanding of medication adherence
among Hispanics, (2) Obtain a deeper understanding of the ways in which language determines how Hispanics are educated about
and use prescribed medications, (3) Elicit recommendations from subject matter experts as well as Hispanics themselves on how
to increase medication adherence and (4) Propose practical approaches to translating these insights into actionable interventions.
Design and Methodologies: The Hispanic Medication Study relied on three key sources of information: (1) A literature review using
health and medical publications, (2) Key informant interviews with subject matter experts in the area of Hispanic health and (3) An
online survey fielded to HolaDoctor’s database of over one million Hispanic health seekers residing in the U.S. and Puerto Rico.
Findings and Results from Literature Review and Key Informant Interviews: The findings from the literature review and key
informant interviews offered a number of common insights and the barriers to good medication adherence. Among these were that:
Hispanics tend to “wait” to bring themselves or their family members to see a doctor, often trying alternative/natural approaches
first; low health literacy has a negative impact on health seeking and adherence; visits to doctors are avoided because employment
is more likely to be hourly wage-based and if they aren’t working, they aren’t earning money; there is a low understanding of how
prescribed medications work or what they are for and how they are to be taken, all leading to distrust they will work and lower
adherence; there is a greater concern about side effects with prescribed medications among Hispanics compared to non-Hispanic
whites; cost of copays can be a serious deterrent for lower income Hispanics. Regarding “what works” to increase adherence,
tactics included: home visits by lay health workers; conducting “show and tell” sessions with Hispanic patients, where the patient or
caretaker is made to handle each medication and tell the provider what each is, how it is used and what it is for; reminders, including
text messaging, are showing promise.
Online Survey — Participants: We conducted an online survey with a total of 1,712 participants, 870 of whom were living in
Puerto Rico and 842 of whom were in the United States. Fifty-one percent were between 35 and 54 years of age; 99 percent of
survey respondents spoke Spanish at home. Three-quarters of the participants had some form of health insurance. Approximately
45 percent of the sample were taking three or more medications on a regular basis. High blood pressure, pain, high cholesterol,
diabetes and acid reflux were the top conditions.
Online Survey — Findings and Results: Survey participants in the U.S. reported feeling more disconnected from their doctor
than those in Puerto Rico due to cultural and language barriers. Doctors were by far the preferred source of information about
HISPANIC MEDICATION ADHERENCE | 2
medications with over 70 percent of respondents preferring a doctor for information on medications in both the U.S. and Puerto Rico.
Conversely, pharmacists were preferred by 24 percent of Puerto Rican respondents compared to just 13 percent of Hispanics in the
U.S. Less than a third of Hispanics ranked high on a standardized medication adherence scale: two-thirds were either moderate
or poor adherers. The top reasons for not taken ones medications were: I forget (40 percent), I felt better (20 percent), high cost
(17 percent). Online information, email and text messaging were the top three things Hispanics felt would help them remember to
take medications. The top five ways that people remembered to take their medications were: pain/feeling worse, having a routine,
alarm or calendar reminders, putting the medications out so they can be seen and knowing they are important for health and
feeling better. When asked what participants thought would help other Hispanics have higher medication adherence, the strongest
recommendation, by far, was more education and information about the condition and the medication itself.
RECOMMENDATIONS AND ACTION ITEMS
Health care providers, health plans and others professionals designing interventions to increase medication adherence among
Hispanics should consider the following:
• Hispanics have told us loud and clear, they need more and better understanding of their medical conditions and the
medications they are being prescribed.
• While non-Hispanics tend to accept information from a wide range of sources, among Hispanics, the doctor is still king.
• Routines, alarms, calendars and simply putting medicines in a place that is easy to see are considered the most effective
tactics for remembering to take one’s treatments.
• Hispanics are connected, mobile and technologically savvy. Online information, emails and text messages were all considered
good ways to receive information and reminders.
Some things that health care educators and providers should do based on this study include:
• Creating information about standard medications and conditions that doctors can give to their patients in the exam rooms —
this is a fast way for doctors to deliver information.
• Providing reminder tools through online and mobile technology to remind individuals to take their medications or take their
medications with them.
• Pairing medication financial assistance programs with information regarding conditions so that patients can access
information and understand how to use their medication.
HISPANIC MEDICATION ADHERENCE | 3
INTRODUCTION
Hispanics are the largest and one of the fastest-growing minority groups in the United States1. By 2025, over 25 percent of the U.S.
population is projected to be of Hispanic ethnicity. Hispanics have traditionally had the lowest rates of health insurance coverage of
any demographic group2. An estimated eight in 10 uninsured Hispanics qualified for Medicaid, the Children’s Health Insurance Plan
(CHIP) or lower costs on monthly premiums through the Health Insurance Marketplace. Since the passage of the Affordable Care
Act, 4.2 million Hispanics (ages 18-64) have gained health insurance coverage, lowering the uninsured rate among Hispanics by 7.7
percent. If all states took advantage of new opportunities to expand Medicaid coverage under the Affordable Care Act, 95 percent
of eligible uninsured Hispanics might qualify for Medicaid, CHIP or programs to help lower the cost of health insurance coverage in
the Marketplace.3
Hispanics have higher rates of certain medical conditions, e.g., diabetes, than non-Hispanic whites4. For nearly all conditions,
Hispanics have lower medication adherence than non-Hispanic whites5. Medication adherence among Hispanics is lower among
Hispanics with heart disease6,7,8 and diabetes9, among other conditions. Hispanic Medicare recipients10,11 and those on psychotropic12
treatments also show significantly lower compliance with medication regimens than non-Hispanic whites.
Empirical data on the attitudes, beliefs and practices of uninsured Hispanics and the use of discount medication programs are
severely lacking. A limited number of interventions have been tested to increase medication compliance among Hispanics13, but
there is still very poor understanding of why Hispanics do not fill their prescriptions and/or adhere to their medication condition
management protocols. This study seeks to increase our understanding of how this increasingly dominant demographic group uses
and adheres to medication protocols.
STUDY OBJECTIVES
The objectives of this study were to:
• Gain a better understanding of medication adherence among Hispanics
• Obtain a deeper understanding of the ways in which language determines how Hispanics are educated about
and use prescribed medications
• Elicit recommendations from subject matter experts as well as Hispanics themselves on how to increase
medication adherence
• Propose practical approaches to translating these insights into actionable interventions
HISPANIC MEDICATION ADHERENCE | 4
STUDY DESIGN AND METHODOLOGIES
The Hispanic Medication Study relied on three key sources of information:
•A literature review using health and medical publications
• Key informant interviews with subject matter experts in the area of Hispanic health
•An online survey fielded to HolaDoctor’s database of over one million Hispanic health seekers residing in the
U.S. and Puerto Rico
In this report, we include the comprehensive findings from these three approaches. A version of the study results will be published
as a shorter white paper as well as in an academic, peer-referenced journal article (forthcoming).
Online Study Population: HolaDoctor operates the largest network of Spanish-language health care websites on the Internet, with over
3.5 million unique Hispanic visitors monthly. Approximately one million of these unique Hispanic visitors reside in the U.S. or Puerto Rico.
HISPANICS ARE ONLINE AND MOBILE
Until recently, online surveys among Hispanics may have missed the lowest-income
consumers, who did not have Internet access. Today, however, nearly 78 percent of
Hispanics in the U.S. and Puerto Rico report using the Internet. As with the general market,
a large and very fast-growing percentage of these consumers access the Internet through
their smartphones or other web-enabled mobile devices. Of the more than millions of pages
of Spanish-language health information HolaDoctor serves up each month, over 70 percent
are accessed through consumers’ mobile devices, and 76 percent of Hispanic Internet users
report accessing the Internet through a mobile device.14
HISPANIC MEDICATION ADHERENCE | 5
Instrument Development: The survey instrument was based on best practices in the medication adherence field. The online
questionnaire included demographic questions, the core set of questions from the MM4 questionnaire15 , culturally relevant questions
particular to Hispanics and open-ended questions to elicit innovative strategies and tactics. A number of subject matter experts
provided input on the survey question set. The final survey contained questions on demographics, health conditions, medication
usage, attitudes, barriers and enablers to better medication compliance.
Recruitment: Hispanic consumers who had opted into to HolaDoctor’s online community were invited to participate in the survey
through an email invitation. Participants who completed the survey were provided with a $10 Amazon gift card. The survey was
fielded over two rounds, one during November 2014 and a second during January 2015.
Analysis: Frequencies tables were generated and stratified by residence (Puerto Rico vs. U.S. mainland). Differences were
determined using chi-square at the p<0.05 significance level.
PROVIDER KEY INFORMANT INTERVIEW RESULTS
Three physicians who regularly care for Hispanic patients participated in the in-depth interviews:
• Dr. Eduardo Montana. Pediatric cardiologist and current chair of the Hispanic Health Coalition of Georgia
• Dr. Flavia Mercado. A pediatrician and former chair of the Hispanic Health Coalition of Georgia
• Dr. Ken Dominguez. A director of HIV/AIDS at the Centers for Disease Control and Prevention and chair of the
CDC Hispanic employees working group
These subject matter experts/providers were interviewed about the barriers to medication adherence among Hispanics and, more
importantly, what they have found works to increase adherence among this population. These key informants also provide input on
the content of the survey instrument.
HISPANIC MEDICATION ADHERENCE | 6
INSIGHTS FROM THE KEY INFORMANTS
The qualitative insights and examples provided by the key informant physicians have been grouped by topic below.
ATTITUDES TOWARD MEDICATIONS AND HESITANCY TO GO TO THE DOCTOR
• Hispanics wait to bring children to the doctor.
• Hispanics need to work and are often paid by the hour, so they are very reluctant to take time to go to the doctor.
• They know going to the doctor “opens up a whole process.” They are hesitant to “get into it all.”
LANGUAGE BARRIERS
• Even if the doctor speaks Spanish, they still often don’t understand what the doctor is saying. It is more than language; it is
also “health literacy.”
PERSISTENCE
• Refills – they usually fill the first script, but then don’t refill it.
• Hispanics are more apt to share medicines.
CHRONIC CONDITIONS
• Chronic conditions are really tough because they need to keep track of so many medications for such a long period.
• They don’t understand that patients have to be on some medications for a long time.
• Asthma. They take curative medication, but they do not consistently take the maintenance meds.
• Case study: Diabetic teen on metformin. His whole family was diabetic. He didn’t take his meds because he didn’t feel bad.
He didn’t understand why he should take it.
CONFLICT WITH SCHOOL
• Schools can make the process even more complicated. The doctor and family need to submit letters and have to be identified,
so sometimes they just want to avoid the whole situation by not reporting asthma to the school.
• Asthma is the biggest chronic problem with children. We (doctors) start by teaching the parents, but “eventually we need to
teach the children.”
• “We providers think that compliance is the most important, but they (the parents and kids) are dealing with lots of other things,
like just getting to school.”
HISPANIC MEDICATION ADHERENCE | 7
UNDERSTANDING MEDICATIONS
• Hispanics are very visual. They often just refer to the color of the pills — white pill, blue pill — but of course lots of pills are the
same color, so that can create problems.
• Some doctors use a visual graph or the PDR.
• I had a patient whose child should be on ADHD meds, but the mom just didn’t want to have her child take it. She resisted and
kept bringing in folk remedies.
• It’s very important that they understand WHY they are taking the medicines. This can be a real issue with Hispanic patients.
POOR UNDERSTANDING OF HOW TO USE MEDICATIONS
• Hispanics often have a very poor understanding of what medicines they have been prescribed and how to take them.
• It’s not uncommon that they put ear drops in the mouth.
• Case study of asthma patient: The child was admitted to the hospital, which gave the parents medications. The mother
already had some medications from the doctor and then got additional medications from the emergency room. The mother
was very confused, so she came to her provider. “I’m not sure which of all these medicines to give my son. I got one from
doctor and one from the hospital,” she said. She brought three bags in to the doctor. She had medications from the doctor,
hospital and emergency room. Some were the same medications, but some were generic and some brand name. Hispanics
often get medications from Walmart that often don’t get recorded in the health plan records.
• What works best is to have them bring all of their medications in to the appointments and have the doctor explain what each
one is for and how they are to be taken.
• In AIDS, the large number of pills is an issue. It works much better if pills can
be combined so they take fewer pills fewer times per day.
• Elderly Hispanics: Need to use a large font and make the instructions clear.
HISPANIC MEDICATION ADHERENCE | 8
SIDE EFFECTS
• Hispanics tend to be very afraid of side effects from Western medicines, but don’t like to complain. But also it is likely that they
just don’t complain to me because I am the doctor.
• The key is to give them a heads up that there may be side effects.
COST
• Medicaid pays for some medications, health insurance others. The doctor has to be very careful to make sure the medications
s/he is prescribing are affordable; otherwise, the patient won’t fill or refill them.
• Cost is the key. If a family is on Medicaid, they will be very compliant. If not, or if they don’t have another form of health
insurance, they won’t.
WILLINGNESS TO TAKE MEDICATIONS
• Antibiotics: Hispanics are very willing to take antibiotics.
• “With kids and medicines, parents are really trying to do the right thing.”
• “I think Hispanics really don’t want to give medicines.” They feel like other things can help first, like traditional cures.
WHAT ELSE WORKS?
• Home visits by lay health workers: they can check to make sure that the meds are stored properly, refrigerated;
and they can do educational follow-up.
• Show and tell: had parents show her how medications were administered.
• Provider recommendations: CDC has found that the strength of the provider recommendation is very important, especially
among pregnant women.
• Reminders: text messaging and phone calls help.
HISPANIC MEDICATION ADHERENCE | 9
SURVEY RESULTS
Study Population: A total of 1,712 Hispanic consumers
Residence
completed the survey. Approximately half of the participants
Puerto Rico
54%
(n=870) were from Puerto Rico, while the rest were living in
Florida
12%
the United States (n=842). The states where they lived were
Other
11%
the top five Hispanic states: California, Florida, Illinois, New
California
8%
Texas
8%
The majority of respondents were women (72 percent).
Illinois
4%
The age distribution of the respondents is presented in the
New York
3%
York and Texas.
second graph at right. Nearly half of respondents were over
45 years old.
Language: The survey was presented in Spanish to a
community that was initially sourced through Spanish-
65+
5%
15-24
5%
5-64
17%
25-34
22%
language health websites and a free prescription medication
program. It is not surprising, then, that most spoke only
Age
Distribution
Spanish at home, or a mix of Spanish and English. Less
than one percent spoke only English at home. As expected,
(n=1,639)
a significantly higher percentage of respondents living in
Puerto Rico spoke only Spanish at home. In a separate
question, 90 percent of participants indicated they prefer to
45-54
26%
35-44
25%
receive health information in Spanish.
WHICH LANGUAGES DO YOU SPEAK AT HOME?*
English and Spanish equally
More Spanish than English
More English than Spanish
Another language
Only Spanish
Only English
TOTAL
United States
169
22%
309
40%
18
2%
5
1%
260
34%
4
1%
414
Puerto Rico
107
12%
344
40%
6
1%
0
0%
405
47%
2
<1%
408
Total
276
17%
653
40%
24
2%
5
0%
665
41%
6
<1%
822
HISPANIC MEDICATION ADHERENCE | 10
Health Insurance: Over three-quarters of the sample
reported having health insurance. Insurance coverage
was significantly higher for those living in Puerto Rico
(93 percent) than those living in the mainland U.S.
(56 percent). The percentage of respondents on
Medicaid, 21 percent, matches national statistics,
which show that 68 million of the 316 million people in
the U.S. are covered by Medicaid at some point during
the year16. For those with insurance, people living in
the U.S. were more likely to have coverage through
Affordable Care Act exchanges (known to Hispanics
as “Obamacare”), while those living in Puerto Rico
were more likely to be covered by private insurance
through a private company.
INSURANCE TYPES FOR THOSE WITH COVERAGE
For those with health insurance, 83 percent indicated that they had prescription drug coverage.
Medicaid
Medicare
Insurance through an employer or spouse’s employer
Private insurance through Obamacare
Private insurance bought directly through a private company
None
TOTAL
United States
79
20%
64
16%
145
37%
69
18%
37
9%
335
44%
762
Puerto Rico
161
22%
118
16%
258
35%
43
6%
167
23%
58
7%
862
Total
240
21%
182
16%
403
35%
112
10%
204
18%
393
24%
1,624
HISPANIC MEDICATION ADHERENCE | 11
MEDICAL CONDITIONS AND HISTORY
Nearly all of the respondents had one or more medical conditions and were taking one or more prescription medications. (See below.)
Number of Medical Conditions and Number of Medications Being Taken
have at least one
medical condition
and take at least
one medication
86%
(n=1,712)
Number of Medical Conditions
0
12%
1
18%
2
17%
3
17%
4
11%
5
7%
6 to 10
13%
11+
3%
Number of Medications Prescribed
0
13%
1
19%
2
16%
3
16%
4
10%
5
8%
6 to 10
13%
11+
3%
Number of Medications Being Taken
0
14%
1
22%
2
19%
3
14%
4
9%
5
8%
6 to 10
12%
11+
3%
The most prevalent medical conditions for which participants were taking medications were high blood pressure, pain, acid reflux
and diabetes. Subjects living in Puerto Rico reported higher usage of medications for conditions.
Which Health Conditions Do You Take Medications For?
50%
n United States n Puerto Rico n Total
43%
40%
37%
37%
34%
31%
30%
20%
18%
23%
22%
20%
30%
29%
23%
22%
20%
19%
15%
10%
17%
14%
14%
14%
9%
8%
20%
20%
18%
19%
24%
23%
22%
8%
5% 5% 5%
0%
0%
Asthma
High
Cholesterol
1% 1% 1%
1%1%
COPD
Diabetes
Pain
Acid Reflux
Anemia
Arthritis
Birth Control High Blood Mental Health/
Hypo-/
Other
Pressure
Depression Hyperthyroidism
HISPANIC MEDICATION ADHERENCE | 12
MEDICATION COMPLIANCE
The MMAS Score is a validated, standardized set of questions that measure medication adherence15. Notably, a low score indicates
high adherence, while a high score indicates low adherence. About 22 percent of the sample had an MMAS score of 0, so were highly
compliant. Approximately 32 percent of the sample had an MMAS score of 3 or 4, so were deemed to have low medication adherence.
35%
MMAS Scores
31%
n United States n Puerto Rico n Total
30%
22%
25%
20%
15%
25%
21%
23%
22%
24% 23%
23%
17%
20%
15%
14%
9%
10%
12%
5%
0%
0
1
2
3
4
The key questions that make up the MMAS are listed in the following table, along with the percentage of participants answering Yes
or No to each one.
Have you ever forgotten to take
medication for your condition?
No
Yes
TOTAL
Have you ever had problems
remembering to take your
medication?
No
Yes
TOTAL
When you feel better, do you
sometimes stop taking your
medications?
No
Yes
TOTAL
If you feel worse when taking
your medication, do you stop
taking it?
No
Yes
TOTAL
United States
330
43%
441
57%
771
503
65%
265
35%
768
463
60%
305
40%
768
486
63%
286
37%
772
Puerto Rico
248
29%
618
71%
866
482
56%
381
44%
863
516
60%
349
40%
865
475
55%
390
45%
865
Total
578
35%
1,059
65%
1,637
985
60%
646
40%
1,631
979
60%
654
40%
1,633
961
59%
676
41%
1,637
HISPANIC MEDICATION ADHERENCE | 13
MEDICATION DISCOUNT CARD
About 40 percent of respondents use a medication discount card to help pay for medications, with a slightly higher usage among
those living in Puerto Rico.
DO YOU USE A DISCOUNT MEDICATION PROGRAM TO HELP PAY FOR YOUR MEDICATION?*
No
Yes, I’m in a program sponsored by a pharmaceutical company
Yes, I’m in a program sponsored by a pharmacy
Yes, I receive a medication discount through the clinic I go to
Yes, I use a medication discount card
Yes, I’m in a different program that decreases my medication costs
TOTAL
United States
Puerto Rico
Total
414
58%
9
1%
44
6%
40
6%
169
24%
38
5%
714
510
64%
7
1%
22
3%
5
1%
221
28%
33
4%
798
924
61%
16
1%
66
4%
45
3%
390
26%
71
5%
1,512
OF THOSE WHO USE MEDICATION DISCOUNT CARDS, ARE THEY UNIVISION CARDS OR OTHER CARDS?
Other
Univision
TOTAL
United States
Puerto Rico
Total
40
26
66
19%
10%
14%
169
235
404
81%
90%
86%
209
261
470
The high percentage of people with medication discount cards who responded that they have a Univision card is due to the fact that
one of the sources of the sample population was people who had signed up for a medication discount card administered by Univision,
EnvisionRx and HolaDoctor.
HISPANIC MEDICATION ADHERENCE | 14
INTERACTING WITH DOCTORS AND HEALTH PROFESSIONALS ABOUT PRESCRIPTION MEDICATIONS:
THE ROLE OF LANGUAGE
When asked “Do you trust your doctor for information about
prescription medications?,” 83 percent indicated that they
always or usually trust their doctor.
When asked “Have you ever felt disconnected from your doctor
because of your culture?,” 23 percent of those living in the U.S.
said that they had, compared to only eight percent of those living
in Puerto Rico. The fact that nearly all doctors in Puerto Rico are
from the island and speak Spanish, whereas in the U.S. there
are few Spanish-speaking, culturally competent physicians, likely
explains this significant difference.
HAVE YOU EVER FELT DISCONNECTED FROM YOUR DOCTOR BECAUSE OF YOUR CULTURE?
No
Yes
TOTAL
United States
Puerto Rico
Total
569
755
1324
77%
92%
85%
170
63
233
23%
8%
15%
739
818
1,557
Interestingly, when participants were asked “How often do you have difficulty communicating with your doctor?,” the rates were
similar among respondents in the U.S. and Puerto Rico.
HOW OFTEN DO YOU HAVE DIFFICULTY COMMUNICATING WITH YOUR DOCTOR?
Usually
Sometimes
Once in a while
Never/Rarely
TOTAL
United States
Puerto Rico
Total
48
35
83
6%
4%
5%
149
143
292
20%
17%
18%
143
137
280
19%
16%
17%
425
536
961
56%
63%
60%
765
851
1,616
HISPANIC MEDICATION ADHERENCE | 15
The preferred source of information about medications was overwhelmingly a doctor, but pharmacists were much more highly
regarded in Puerto Rico than in the U.S.
Preferred Source of Information about Medications
(n=1,712)
80%
78%
n United States n Puerto Rico
72%
70%
60%
50%
40%
24%
30%
13%
20%
10%
0%
2% 1%
Doctor
Pharmacist
Nurse
2% 1%
5%
3%
Family Member Health Promoter
1% 1%
Friend
ADHERENCE
Overwhelmingly, the most common reason participants did not take their medication was because they forgot.
HISPANIC MEDICATION ADHERENCE | 16
When You Don’t Take Your Medication, What Is the Main Reason You Don’t Take It?
n United States n Puerto Rico n Total
50%
40%
30%
20%
10%
0%
Financial
reasons/
too
expensive
It’s too
difficult to
go to the
pharmacy
I feel
better
I feel
worse
Need to
get a refill
I don’t
understand
why I have
to take it
I forget
I don’t
need it
anymore
Other
N/A
(I always
take them)
AFFORDABILITY
Nearly 40 percent of the survey participants felt that their medications were either “unaffordable” (28 percent) or “very unaffordable”
(11 percent).
WAYS TO IMPROVE MEDICATION ADHERENCE
The survey included a series of questions about things Hispanics felt would help them to remember to take medications. Those
answering “yes” to closed-ended questions about specific tactics are presented in the graphic below.
WAYS TO REMEMBER TO TAKE MEDICATION: PERCENT ANSWERING “YES”
(n=1,712)
ONLINE INFORMATION
EMAIL REMINDERS
TEXT REMINDERS
@
United States
Puerto Rico
87%
90%
United States
Puerto Rico
56%
57%
United States
Puerto Rico
59%
60%
HISPANIC MEDICATION ADHERENCE | 17
We also asked the open-ended question “What helps you remember your medication?” The results were grouped and are presented
in the following table. Besides feeling pain or discomfort, the three most common responses referenced the importance of routine,
alarms/calendars and having the pills in a place where they can easily be seen.
WHAT HELPS YOU REMEMBER YOUR MEDICATION?
Number of Mentions
Pain and/or feeling worse
110
Have a certain routine
108
Alarm/calendar reminder
90
Seeing the medications/putting them where they can be seen
74
Knowing it’s important for my health/wanting to feel better
71
Family/individual reminds me
38
Pillbox
27
Other reminders (calls, emails, written, texts, phone apps)
26
Other
12
Better financial access
2
REPRESENTATIVE QUOTATIONS FROM
INDIVIDUALS WHEN ASKED WHAT HELPS
THEM REMEMBER THEIR MEDICATION
• I have a routine, and I also write it on a note on my fridge to be able to remember.
• Knowing that some medications are necessary to get better from whatever
illness one is suffering from and avoid something more serious or causing the
illness to get worse or become fatal.
• When I’m feeling well, I always remember.
• A family member reminds me, and I note it on my cell phone calendar.
• My son is my reason for staying healthy. He is only five years old, and I am a
widow, so it’s just us.
• I am very forgetful when it comes to taking medications, but if someone
reminds me, it helps me to remember.
HISPANIC MEDICATION ADHERENCE | 18
The final question asked the participants was “What would help Hispanics take their medication?” In other research, we have found
that this question is revealing in that it takes the focus away from individual respondents and forces them to think about ways that might
work for others like them. The overwhelming majority of responses indicated that Hispanics feel that better education and information
about both the medical condition and the medications would be helpful in improving medication adherence. Alarms, reminders and
routines were also mentioned, as they were in the previous question. Some suggested that better financial assistance and access
(e.g., lower prices) would be helpful. Notably, only a small number of people felt that more information in Spanish or Spanish-speaking
doctors was key to better adherence. This may be because most medication instructions are now available in Spanish.
WHAT WOULD HELP HISPANICS TAKE THEIR MEDICATION?
Number of Mentions
More education/information regarding the condition and medication
168
Alarms/reminders through alarms or email
71
Better access/financial help to buy medications
63
Establishing a routine
57
Text messaging/applications
37
Reminders from family members
28
Other
20
Spanish-language materials/information
7
Other written/television reminders
6
Better doctors/doctors who speak Spanish
5
Pillbox
4
REPRESENTATIVE QUOTATIONS
WHEN ASKED “WHAT WOULD HELP
HISPANICS TAKE THEIR MEDICATION?”
• Being better informed and knowing the benefits associated with taking them,
without ignoring the risks associated with taking them.
• Knowing that in order to make progress as a family, they need to be healthy.
• Educating about the illness and learning more about it.
• First being able to get it, then individually coming up with their own system that
helps them remember to take it.
• Having better access to information in a clear, complete and simple manner,
either through a doctor or pharmacist who is trusted.
• Having access to good medical treatment and advice in their own language.
HISPANIC MEDICATION ADHERENCE | 19
SUMMARY AND RECOMMENDATIONS
This study sought to better understand medication usage and adherence among the fast-growing and increasingly important Hispanic
population. The large survey population was representative of Hispanics living in the U.S. or Puerto Rico and enabled us to compare
and contrast whether there were differences between these two groups.
SOME OF THE KEY FINDINGS WE CAN DRAW FROM OUR RESEARCH ARE THE FOLLOWING
• Among this study population of mostly 25- to 55-year-old Hispanic females, many suffer from a number of medical conditions
and are taking multiple medications for these maladies.
• Like non-Hispanics, understanding these conditions and the prescribed treatments can be difficult. Most do not take their
medications at times.
• Hispanics trust their doctor most for information about their medications. In Puerto Rico, pharmacists are highly trusted.
Notably, nurses were not well trusted for medication information.
• Less than a third of Hispanics ranked high on a standardized medication adherence scale: two-thirds were either moderate or
poor adherers.
• Establishing a routine, setting up alarms and reminders and placing the medications in a place that is easy to see are key
tactics to remember treatments.
• Online information, email reminders and text messaging were all perceived as valuable ways to increase adherence.
• Through an open-ended question set, Hispanics suggested that “better information about the medical conditions as well as
the medications themselves” was sorely needed and that helping people understand these better could significantly increase
medication adherence.
HISPANIC MEDICATION ADHERENCE | 20
RECOMMENDATIONS
Health care providers, health plans and other professionals designing interventions to increase medication adherence among
Hispanics should consider the following:
• Hispanics have told us loud and clear that they need more and better understanding of their medical conditions and the
medications they are being prescribed.
• While non-Hispanics tend to accept information from a wide range of sources, among Hispanics, the doctor is still king.
• Routines, alarms, calendars and simply putting medicines in a place that is easy to see are considered the most effective
tactics for remembering to take one’s medications.
• Hispanics are connected, mobile and technologically savvy. Online information, emails and text messages were all considered
good ways to receive information and reminders.
ACTION ITEMS
• Create information about standard medications and conditions that doctors can give to their patients in the exam rooms —
this is a fast way for doctors to deliver information.
• Provide reminder tools through online and mobile technology to remind individuals to take their medications or take their
medications with them.
• Pair medication financial assistance programs with information regarding conditions so that patients can access information
and understand how to use their medication.
HISPANIC MEDICATION ADHERENCE | 21
ABOUT THE AUTHORS
ABOUT HOLADOCTOR
HolaDoctor Inc. (www.holadoctor.net) is the leading Hispanic health marketing company in the U.S. HolaDoctor owns and operates
the most popular Spanish-language health care website online (www.holadoctor.com) and is the exclusive health partner to Univision
Interactive. The company provides strategic consulting, marketing solutions and culturally relevant programs to health plans,
providers, governmental agencies and other health care entities. HolaDoctor has offices in Atlanta, Miami and Mexico City.
ABOUT ENVISIONRX
EnvisionRxOptions is a health care and pharmacy benefit management (PBM) company headquartered in Twinsburg, Ohio. We
have over 1,500 employees supporting a rapidly growing membership base of over 23 million members, creating savings for them
as well as thousands of plan sponsors. Rite Aid’s acquisition of Envision in 2015 brings together two national health care companies
that give consumers more pharmacy options and give plan sponsors improved manufacturer relationships and analytic capabilities.
ABOUT THE AUTHORS
Dirk G. Schroeder, ScD, MPH: Dr. Schroeder is the executive VP and Chief Health Officer at HolaDoctor Inc. He is also an adjunct
associate professor of global health at Emory University. He is a recognized expert in Hispanic health issues, including ways to
increase access and address health disparities. Dr. Schroeder has lived and worked throughout Latin America as well as Southeast
Asia. He has doctoral and master’s degrees in international health from Johns Hopkins University and a post-doc from Cornell. He
completed his undergraduate work, with honors and distinction, at Stanford University.
Meryam Alaoui: As general manager for EnvisionSavings, the direct-to-consumer line of business for EnvisionRxOptions, a
national, fully integrated health care company, Ms. Alaoui oversees all prescription discount programs and copay buy-down
offerings administered nationally by EnvisionRx. In this capacity, she works with public- and private-sector clients, including states,
municipalities, nonprofit organizations and employers, to deliver valuable services to more than 10 million lives. Prior to joining
Envision in 2009, Ms. Alaoui held executive roles with American Express in Finance, Operations, Tax, Treasury and Merchant
Services. Before American Express, she worked for the National Council on Compensation Insurance (NCCI) overseeing the
Assigned Risk investment portfolio.
Brianna Keefe-Oates, MPH: Ms. Keefe-Oates serves as part of the strategic consulting branch of HolaDoctor. She has most
recently worked on educational outreach programs focused on educating individuals about the Affordable Care Act. Ms. Keefe-Oates
also has experience implementing health prevention projects with Hispanics in the Southeast U.S. and nationally. Ms. Keefe-Oates
has worked on research and outreach projects in Paraguay and the Dominican Republic, where she spent three years as a Peace
Corps volunteer. Ms. Keefe-Oates received a bachelor’s degree in Latin American studies from Macalester College and a master of
public health degree from Emory University.
HISPANIC MEDICATION ADHERENCE | 22
CONTACTS
Dr. Dirk G. Schroeder
Principal Investigator
EVP & Chief Health Officer
HolaDoctor, Inc.
900 Old Roswell Lakes Parkway, Suite 230
Roswell, Georgia 30075
[email protected]
(678) 749-6772
HISPANIC MEDICATION ADHERENCE | 23
EXHIBIT 1: HISPANIC MEDICATION ADHERENCE STUDY –
COMPLETE RESPONSES TO ALL QUESTIONS
SECTION A: TOTAL RESPONSES
United States
842
49%
Puerto Rico
870
51%
Grand Total
1,712
100%
SECTION B: DEMOGRAPHICS
SEX*
Female
Male
TOTAL
United States
Puerto Rico
Total
516
649
1165
68%
75%
72%
244
212
456
32%
25%
28%
760
861
1,621
HISPANIC MEDICATION ADHERENCE | 24
AGE
15-24
25-34
35-44
45-54
55-64
65+
TOTAL
United States
Puerto Rico
Total
42
39
81
5%
4%
5%
197
171
368
26%
20%
22%
222
191
413
29%
22%
25%
157
270
427
20%
31%
26%
118
156
274
15%
18%
17%
34
42
76
4%
5%
5%
770
869
1,639
STATE/TERRITORY RESIDENCE
Puerto Rico
54%
Florida
12%
Other
11%
California
8%
Texas
8%
Illinois
4%
New York
3%
HISPANIC MEDICATION ADHERENCE | 25
WHICH LANGUAGES DO YOU SPEAK AT HOME?*
English and Spanish equally
More Spanish than English
More English than Spanish
Another language
Only Spanish
Only English
TOTAL
United States
Puerto Rico
Total
169
107
276
22%
12%
17%
309
344
653
40%
40%
40%
18
6
24
2%
1%
2%
5
0
5
1%
0%
0%
260
405
665
34%
47%
41%
4
2
6
1%
<1%
<1%
414
408
822
IN WHICH LANGUAGE DO YOU PREFER TO RECEIVE INFORMATION ABOUT YOUR MEDICATIONS?
Spanish
English
TOTAL
United States
Puerto Rico
Total
675
788
1463
89%
91%
90%
84
74
158
11%
9%
10%
759
862
1,621
United States
Puerto Rico
Total
335
58
393
44%
7%
24%
427
862
1231
56%
93%
76%
762
862
1,624
DO YOU CURRENTLY HAVE INSURANCE?**
No
Yes
TOTAL
HISPANIC MEDICATION ADHERENCE | 26
FOR THOSE WHO HAVE INSURANCE, WHAT KIND OF INSURANCE?*
United States
Puerto Rico
Total
79
161
240
20%
22%
21%
Medicaid
Medicare
Insurance through an employer or spouse’s employer
Private insurance through Obamacare
Private insurance bought directly through a private company
TOTAL
64
118
182
16%
16%
16%
145
258
403
37%
35%
35%
69
43
112
18%
6%
10%
37
167
204
9%
23%
18%
394
747
1141
DOES YOUR INSURANCE COVER YOUR PRESCRIPTION MEDICATIONS?
No
Yes
TOTAL
United States
Puerto Rico
Total
67
139
206
16%
18%
17%
346
629
975
84%
82%
83%
413
768
1181
HISPANIC MEDICATION ADHERENCE | 27
SECTION C: MEDICAL HISTORY
HOW MANY MEDICAL CONDITIONS DO YOU HAVE?
0: 12%
1: 18%
2: 17%
3: 17%
4: 11%
5: 7%
6-10: 13%
11+: 3%
HOW MANY MEDICATIONS ARE YOU CURRENTLY PRESCRIBED?
11+
Six to 10
Five
Four
Three
Two
One
Zero
TOTAL
United States
Puerto Rico
Total
15
38
53
2%
4%
3%
76
146
222
9%
17%
13%
40
95
135
5%
11%
8%
66
99
165
8%
11%
10%
128
143
271
15%
16%
16%
169
143
271
15%
16%
16%
193
130
323
23%
15%
19%
155
76
231
18%
9%
13%
842
879
1,712
HISPANIC MEDICATION ADHERENCE | 28
HOW MANY MEDICATIONS ARE YOU CURRENTLY TAKING?
United States
Puerto Rico
Total
9
33
42
1%
4%
2.5%
71
134
205
8%
15%
12%
36
94
130
4%
11%
8%
63
89
152
7%
10%
9%
11+
Six to 10
Five
Four
Three
Two
One
Zero
TOTAL
108
132
240
13%
15%
14%
181
149
330
22%
17%
19%
207
173
380
25%
20%
22%
167
66
233
20%
8%
14%
842
870
1,712
For Which Conditions Are You Currently Prescribed Medication?
(Respondents were able to select more than one)
n United States n Puerto Rico n Total
50%
43%
40%
37%
37%
34%
31%
30%
20%
18%
23%
22%
20%
30%
29%
23%
22%
20%
19%
18%
19%
15%
10%
24%
23%
22%
17%
14%
14%
14%
9%
8%
20%
20%
8%
5% 5% 5%
0%
0%
Asthma
High
Cholesterol
1% 1% 1%
1%1%
COPD
Diabetes
Pain
Acid Reflux
Anemia
Arthritis
Birth Control
High Blood Mental Health/
Hypo-/
Other
Pressure
Depression Hyperthyroidism
HISPANIC MEDICATION ADHERENCE | 29
SECTION D: MMAS
MMAS Overall Average: 1.8 (1-2=Moderately adherent)
MMAS PR: 2.0
MMAS Other: 1.5
MMAS Scores
35%
n United States n Puerto Rico n Total
31%
30%
22%
25%
20%
15%
25%
21%
23%
22%
24% 23%
23%
17%
20%
15%
14%
9%
10%
12%
5%
0%
0
1
2
3
4
HAVE YOU EVER FORGOTTEN TO TAKE MEDICATION FOR YOUR CONDITION?**
United States
No
Yes
TOTAL
Puerto Rico
Total
330
248
578
43%
29%
35%
441
618
1059
57%
71%
65%
771
866
1,637
HAVE YOU EVER HAD PROBLEMS REMEMBERING TO TAKE YOUR MEDICATION?**
No
Yes
TOTAL
United States
Puerto Rico
Total
503
482
985
65%
56%
60%
265
381
646
35%
44%
40%
768
863
1,631
HISPANIC MEDICATION ADHERENCE | 30
WHEN YOU FEEL BETTER DO YOU SOMETIMES STOP TAKING YOUR MEDICATIONS?
No
Yes
TOTAL
United States
Puerto Rico
Total
463
516
979
60%
60%
60%
305
349
654
40%
40%
40%
768
865
1,633
IF YOU FEEL WORSE WHEN TAKING YOUR MEDICATION, DO YOU STOP TAKING IT?**
No
Yes
TOTAL
United States
Puerto Rico
Total
486
475
961
63%
55%
59%
286
390
676
37%
45%
41%
772
865
1,637
HISPANIC MEDICATION ADHERENCE | 31
SECTION E: INITIAL PRESCRIPTION
DO YOU USE A DISCOUNT MEDICATION PROGRAM TO HELP PAY FOR YOUR MEDICATION?*
United States
No
Yes, I’m in a program sponsored by a pharmaceutical company
Yes, I’m in a program sponsored by a pharmacy
Yes, I receive a medication discount through the clinic I go to
Yes, I use a medication discount card
Yes, I’m in a different program that decreases my medication costs
TOTAL
Puerto Rico
Total
414
510
924
58%
64%
61%
9
7
16
1%
1%
1%
44
22
66
6%
3%
4%
40
5
45
6%
1%
3%
169
221
390
24%
28%
26%
38
33
71
5%
4%
5%
714
798
1,512
OF THOSE WHO USE MEDICATION DISCOUNT CARDS, ARE THEY UNIVISION CARDS OR OTHER CARDS?
Other
Univision
TOTAL
United States
Puerto Rico
Total
40
26
66
19%
10%
14%
169
235
404
81%
90%
86%
209
261
470
HISPANIC MEDICATION ADHERENCE | 32
HOW FREQUENTLY DO YOU TRUST THE INFORMATION THAT YOUR DOCTOR GIVES YOU REGARDING YOUR HEALTH
AND MEDICATION?*
Always
Usually
Sometimes
Once in a while
Never/rarely
TOTAL
United States
Puerto Rico
Total
295
337
632
40%
42%
41%
289
357
646
40%
44%
42%
65
69
134
9%
9%
9%
54
34
88
7%
4%
6%
27
12
39
4%
2%
3%
730
809
1,539
HAVE YOU EVER FELT DISCONNECTED FROM YOUR DOCTOR BECAUSE OF YOUR CULTURE?**
No
Yes
TOTAL
United States
Puerto Rico
Total
569
755
1324
77%
92%
85%
170
63
233
23%
8%
15%
739
818
1,557
HISPANIC MEDICATION ADHERENCE | 33
HOW OFTEN DO YOU HAVE DIFFICULTY COMMUNICATING WITH YOUR DOCTOR?
Usually
Sometimes
Once in a while
Never/rarely
TOTAL
United States
Puerto Rico
Total
48
35
83
6%
4%
5%
149
143
292
20%
17%
18%
143
137
280
19%
16%
17%
425
536
961
56%
63%
60%
765
851
1616
WHO WOULD YOU PREFER TO GIVE YOU INFORMATION ABOUT HOW TO TAKE YOUR MEDICATION?*
Friend
Doctor
Nurse
Family member
Pharmacist
Health promoter
TOTAL
United States
Puerto Rico
Total
4
1
5
<1%
<1%
<1%
611
620
1231
78%
72%
75%
12
4
16
2%
<1%
1%
16
12
28
2%
1%
2%
102
206
308
13%
24%
19%
37
22
59
5%
3%
4%
782
865
1647
HISPANIC MEDICATION ADHERENCE | 34
SECTION F: FULFILLMENT
HOW OFTEN DO YOU HAVE DIFFICULTY COMMUNICATING WITH YOUR PHARMACIST?*
Always
Usually
Sometimes
Once in a while
Never/rarely
TOTAL
United States
Puerto Rico
Total
30
15
45
4%
2%
3%
29
25
54
4%
3%
3%
112
100
212
14%
12%
13%
120
106
226
15%
12%
14%
502
614
1116
63%
71%
68%
793
860
1653
United States
Puerto Rico
Total
23
6
29
3%
1%
2%
30
21
51
4%
2%
3%
188
147
265
15%
17%
16%
146
161
307
18%
19%
19%
475
524
999
60%
61%
61%
792
859
1651
HOW OFTEN DO YOU HAVE DIFFICULTY REFILLING YOUR PRESCRIPTION?
Always
Usually
Sometimes
Once in a while
Never/rarely
TOTAL
HISPANIC MEDICATION ADHERENCE | 35
SECTION G: ADHERENCE
When You Don’t Take Your Medication, What Is the Main Reason You Don’t Take It?
50%
40%
30%
20%
10%
0%
Financial
reasons/
too
expensive
It’s too
difficult to
go to the
pharmacy
I feel
better
I feel
worse
Need to
get a refill
I don’t
understand
why I have
to take it
I forget
I don’t
need it
anymore
Other
N/A
(I always
take them)
HOW AFFORDABLE ARE YOUR PERSONAL MEDICATIONS?*
Very affordable
Affordable
Unaffordable
Very unaffordable
TOTAL
United States
Puerto Rico
Total
171
119
290
22%
14%
18%
323
411
734
41%
48%
44%
206
252
458
26%
29%
28%
95
82
177
12%
10%
11%
795
864
1659
HISPANIC MEDICATION ADHERENCE | 36
IF YOU READ ADDITIONAL INFORMATION ONLINE ABOUT YOUR CONDITION AND MEDICATION,
WOULD IT HELP YOU TAKE YOUR MEDICATION?
No
Yes
TOTAL
United States
Puerto Rico
Total
103
86
189
13%
10%
11%
691
777
1468
87%
90%
89%
794
863
1657
United States
Puerto Rico
Total
351
369
720
44%
43%
44%
442
492
934
56%
57%
56%
793
861
1654
United States
Puerto Rico
Total
157
183
340
42%
40%
41%
221
271
492
59%
60%
59%
378
454
832
WOULD EMAIL REMINDERS HELP YOU TAKE YOUR MEDICATION?
No
Yes
TOTAL
WOULD TEXT REMINDERS HELP YOU TAKE YOUR MEDICATION?
No
Yes
TOTAL
WHAT USUALLY HELPS YOU REMEMBER TO TAKE YOUR MEDICATION?
Number of Mentions
Pain and/or feeling worse
110
Have a certain routine
108
Alarm/calendar reminder
90
Seeing the medications/putting them where they can be seen
74
Knowing it’s important for my health/wanting to feel better
71
Family/individual reminds me
38
Pillbox
27
Other reminders (calls, emails, written, texts, phone apps)
26
Other
12
Better financial access
2
HISPANIC MEDICATION ADHERENCE | 37
WHAT WOULD HELP HISPANICS TAKE THEIR MEDICATION?
Number of Mentions
More education/information regarding the condition and medication
168
Alarms/reminders through alarms or email
71
Better access/financial help to buy medications
63
Establishing a routine
57
Text messaging/applications
37
Family or other person helping them to remember
28
Other
20
Spanish-language materials/information
7
Other written/television reminders
6
Better doctors/doctors who speak Spanish
5
Pillbox
4
HISPANIC MEDICATION ADHERENCE | 38
REFERENCES
U.S. Census Community Survey, 2013.
1
U.S. Census Community Survey, 2013.
2
http://www.hhs.gov/healthcare/facts-and-features/fact-sheets/aca-working-latino-community/index.html.
3
HHS Office of Minority Health, 2013.
4
Colby JA, Wang F, Chhabra J, Perez-Escamilla R. Predictors of medication adherence in an urban Latino community with healthcare disparities. J
Immigr Minor Health. 2012 Aug;14(4):589-95.
5
Zhang Y, Baik SH. Race/ethnicity, disability and medication adherence among Medicare beneficiaries with heart failure. J Gen Intern Med. 2014
Apr;29(4):602-7.
6
Zhang Y, Baik SH, Chang CC, Kaplan CM, Lave JR. Disability, race/ethnicity and medication adherence among Medicare myocardial infarction
survivors. Am Heart J. 2012 Sep;164(3):425-433.e4.
7
Lauffenburger JC, Robinson JG, Oramasionwu C, Fang G. Racial/ethnic and gender gaps in the use of and adherence to evidence-based preventive
therapies among elderly Medicare Part D beneficiaries after acute myocardial infarction. Circulation. 2014 Feb 18;129(7):754-63.
8
Parada H Jr, Horton LA, Cherrington A, Ibarra L, Ayala GX. Correlates of medication nonadherence among Latinos with type 2 diabetes. Diabetes
Educ. 2012 Jul-Aug;38(4):552-61.
9
Gaskin DJ, Briesacher BA, Limcangco R, Brigantti BL. Exploring racial and ethnic disparities in prescription drug spending and use among
Medicare beneficiaries. Am J Geriatr Pharmacother. 2006 Jun;4(2):96-111.
10
Frankenfield DL, Wei II, Anderson KK, Howell BL, Waldo D, Sekscenski E. Prescription medication cost-related non-adherence among Medicare
CAHPS respondents: disparity by Hispanic ethnicity. J Health Care Poor Underserved. 2010 May;21(2):518-43.
11
Lanouette NM, Folsom DP, Sciolla A, Jeste DV. Psychotropic medication nonadherence among United States Latinos: a comprehensive literature
review. Psychiatr Serv. 2009 Feb;60(2):157-74. doi: 10.1176/appi.ps.60.2.157. Review.
12
Hu D, Juarez DT, Yeboah M, Castillo TP. Interventions to increase medication adherence in African-American and Latino populations: a literature
review. Hawaii J Med Public Health. 2014 Jan;73(1):11-8.
13
Lopez, H, Gonzalez-Barrera, A, Patten, E. “Internet Use,” Closing the Digital Divide: Latinos and Technology Adoption. Pew Research Center,
Hispanic Trends. 7 March, 2013.
14
Pedersini, R, Isherwood, G, Vietri, J. “Harmonizing measurement of adherence across the 4 item and 8 item Moriskey Medication Adherence Scale
using cross-sectional data from patients treated for irritable bowel syndrome.” Kantar Health, Poster presented at the ISPOR 18th Annual European
Congress, Dublin, Ireland. 2-6 November, 2013.
15
HHS and U.S. Census, 2015.
16
*=Could be a significant difference between Puerto Rican respondents and all other respondents, but difficult to determine
**=Significant difference
HISPANIC MEDICATION ADHERENCE | 39