The Healthy People initiative — a national effort that sets goals and objectives to improve the health and wellbeing of those in the United States — defines social determinants of health (SDOH) as follows: "SDOH are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks." One area we see SDOH impacting in a significant way is medication adherence. Healthcare organizations looking to improve their patients' medication adherence must consider the potential effects of SDOH and take steps to help reduce or eliminate barriers that contribute to nonadherence.
Let's look at five ways social determinants of health can negatively affect medication adherence.
1. Economic instability forces difficult decisions
Patients can't adhere to a medication regimen without their medications. Unfortunately, millions of Americans do not fill their prescriptions due to costs. A recent study from Gallup and West Health revealed that an estimated 2.3 million seniors and 15.5 million adults — or about 7% of all Americans — were unable to pay for at least one doctor-prescribed medication in their household.
Other alarming results from the survey:
- 10% of participants reported skipping dosages in the prior 12 months as a way of saving medicine and money.
- Among respondents in households earning less than $48,000 annually, 18% report that they or someone in their household had skipped a pill.
- Among respondents with three or more chronic conditions, or eight or more prescriptions, reports of being unable to pay for a prescribed drug in the household reach 11% and 18%, respectively.
As we noted in our medication adherence guide, "With higher costs in medication becoming all too common, some patients are faced with the difficult choice of paying their bills or paying for medications. This often results in patients choosing not to pick up medications or rationing what they do have, thus not taking the medication as prescribed."
It's not surprising that food insecurity is also associated with medication nonadherence. After all, when individuals are forced to choose between paying for food and paying for medications, the former is likely to almost always win out.
2. Housing insecurity introduces a slew of challenges
Uncertainty about housing affects medication adherence in many ways. Cost, as we just discussed, is one of the most significant. As Harvard University's "State of the Nation’s Housing 2020 report" notes, the COVID-19 pandemic came as the United States was already facing crisis-level housing affordability issues. In 2019, more than 37 million households were "housing cost burdened," spending 30% or more of their income on housing. Meanwhile, 1 in 7 households were "severely cost burdened," spending half or more of their income on housing.
Furthermore, cost burdens were greatest among lower-income households. For those households earning less than $30,000, 81% of renters and 64% of homeowners were cost burdened. As the United Way notes, "Paying for shelter should always be the first priority, so you continue to have a roof over your head."
Now let's consider what happens to medication management and adherence when someone is forced to move. This can disrupt:
- a patient's medication regimen routine;
- where the patient is receiving healthcare services and prescriptions;
- who is assisting with medication management;
- where the patient is filling and refilling prescriptions;
- whether the patient can get where they need to in order to fill and refill prescriptions; and
- delivery of medications.
These issues and others can contribute to prescriptions not being filled and refilled, changes to a regimen, lost or misplaced drugs, and more problems that can contribute to medication nonadherence.
3. Lack of transportation is a highly effective medication adherence deterrent
A patient's ability to get where they need to so they can meet with a prescriber and/or fill and refill prescriptions can directly affect medication adherence. In fact, transportation is an SDOH that we identified as one of the challenges with medication adherence in this blog post. In the piece, we noted, "Many lower income, elderly, and disabled patients do not own a car and may not have easy access to bus or subway transportation either. This isn’t limited to rural patients; many urban residents live in non-serviceable areas, or their mobility issues limit them from taking certain forms of public transport. And the cost of a taxi is usually not in their budget."
An analysis of literature on the prevalence of transportation barriers to healthcare access, published in the Journal of Community Health, found the following:
- One study showed that following hospital discharge, patients reporting difficulty visiting the pharmacy had lower prescription fill rates than those not reporting difficulty (20% vs. 55% respectively). Additionally, 65% of patients felt transportation assistance would improve medication use after discharge.
- Another study examining the causes for diabetic ketoacidosis admissions at Grady Memorial Hospital in Atlanta found that about two-thirds of admissions were related to stopping insulin and half of those patients cited either lack of money for insulin or for transportation to get their medicine.
- An online survey study of the relationship between transportation barriers and anti-epileptic use found that 45% of respondents who could not drive said they would miss fewer doses of their medications if transportation was not a problem.
- A cohort study of nearly 47,000 Medicaid patients found that restriction of Medicaid payments for transportation resulted in decreased medication refills.
Fortunately, transportation is not as significant of a contributor to medication adherence shortcomings as it used to be since patients can now turn to a variety of helpful options. These include patient transportation services like Ride Health, prescription delivery services, free shipping by pharmacies, and the increasing availability of 90-day prescriptions that helps reduce the number of trips.
4. Job insecurity brings health insurance challenges
As Fortune reported, research by Alexander Bick of Arizona State University and Adam Blandin of Virginia Commonwealth University revealed that among workers who had a job in February 2020, almost 37% were no longer with their employer a year later. Almost 26% had a different employer, and the remaining 11% were out of a job.
Job insecurity affects the issues we've already highlighted: economic, food, transportation, and housing stability. It also affects health insurance coverage. Job changes involve changes or loss in job-based insurance and job losses mean eventual loss of such insurance. While those who lose jobs still have options for securing coverage (e.g., buying a plan through the Health Insurance Marketplace, signing up for COBRA), this can be a time-consuming process and one that may lead to increased costs, lapses in coverage, reductions or other changes in coverage, and patient concern about how insurance changes will affect coverage and costs.
All these factors can lead to a decrease in the usage of healthcare services, including those that lead to and support the prescribing, filling, and proper usage of medications. As a study published in the American Journal of Public Health notes, "Job loss was significantly associated with the increased risk of unmet healthcare needs," and McKesson reports that uninsured people are nearly three times as likely to not take their medication as prescribed as a way to help reduce costs.
5. Literacy skills can make medication adherence even more of an uphill battle
Health literacy, as defined by the Health Resources & Services Administration (HRAS), is the "degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions." Low health literacy, HRSA notes, is more prevalent among older adults, minority populations, those who have low socioeconomic status, and medically underserved people.
Low health literacy has also been shown to negatively affect medication adherence. In fact, HRSA includes "understanding directions on medicine" as one of the instances when patients with low health literacy may have difficulty. The CDC has a page dedicated to medications as a health literacy topic, which states, "Evidence suggests that health literacy plays a significant role in determining how well patients interpret medication labels and take nonprescription and prescription drugs safely and appropriately."
A column in the Journal of Health Communication discusses the role of health literacy as a contributor to the concept of "unintentional medication nonadherence." The authors note that a greater appreciation for the complexity of demands placed on patients by the healthcare system has helped shift the focus from viewing the root cause of nonadherence problems being the patient and their lack of desire or interest in maintaining adherence to the quality and navigability of health systems and the way health information is provided to patients.
Social Determinants of Health: A Substantial Contributor to Medication Nonadherence
The five ways that we highlight in this piece are far from the only ways that social determinants of health are directly or indirectly leading to medication adherence challenges and shortfalls. Consider access to nutritious foods, which is an SDOH noted on the Healthy People website. Poor access can raise the risk of health conditions and chronic diseases. These can lead to patients needing to take more medications, and we know taking more medications creates more adherence challenges.
Even something like polluted air, another Healthy People SDOH example, can contribute to medication adherence struggles. Research shows that air pollution can worsen asthma symptoms. If someone experiences or worries about experiencing worsening symptoms when they leave their home to fill a prescription or pick up a refill, they may choose to postpone their trip. Such a delay can lead to a patient starting a prescription later than intended or causing a lapse in medication therapy.
The key takeaway: Social determinants of health can have profound effects on medication adherence. Organizations working to improve adherence for their patient population must engage in discussions with patients around SDOH and work to identify the issues most likely to create obstacles to successful adherence. Organizations must also be prepared to provide support, guidance, and resources to help their patients overcome these barriers to adherence. For assistance with such efforts, consider downloading our white paper, "Medication Management Challenges and Opportunities for Payers and Providers."