12/02/21

SDoH & Medication Adherence — The Basics

WithMe Team

The Centers for Disease Control and Prevention (CDC) states that 3.8 billion prescriptions are written every year, but one in five of these prescriptions is never filled. Of the prescriptions that are filled, 50% aren’t correctly followed.

One thing is clear: America has a medication adherence problem. Patient education and medication reminders are key to addressing the problem, but non-medical factors such as a person's proximity to a pharmacy may be crucial determinants of their ability to adhere to their medication as prescribed. Consider a simple example - it’s difficult to take your medication as prescribed if you can’t afford the prescription.

At WithMe Health, we recognize that achieving positive medication outcomes requires considering the socio-economic, cultural, and environmental factors that drive adherence rates. It’s why we contextualize all of our patient engagement with these social determinants of health, to address barriers to adherence and drive the best possible member health outcomes.

What are social determinants of health?

The World Health Organization (WHO) describes social determinants of health (SDoH) as non-medical factors that shape health outcomes. These factors include conditions where a person is born, grows, learns, lives, works, plays, and the social processes, policies, and programs that define their living conditions.

National Academy of Medicine research shows that SDoH may constitute 80% to 90% of the modifiable contributors to health outcomes. SDoH play a critical role in a person’s functioning, health, and quality of life and are also a significant driver of health inequity, the unequal potential of groups of people to access and enjoy quality healthcare interventions and reach optimal health and wellbeing.

This disparity in healthcare costs the economy $309 billion annually and is also why there may be up to a 15-year difference in life expectancy between the most privileged and least privileged U.S. populations.

SDoH are the socio-economic, political, cultural, environmental circumstances that influence health and medication outcomes. Here’s a non-exhaustive list:

  1. Education

  2. Housing

  3. Income

  4. Gender

  5. Sexual orientation

  6. Culture

  7. Social safety net

  8. Social capital

  9. Time

  10. Transportation access

  11. Work

  12. Social support

  13. Language literacy

  14. Digital literacy and internet connectivity

  15. Access to food and clean water

  16. Religion

Taking into account these sorts of factors is the first step towards improving member outcomes.

How do SDoH impact medication adherence?

Consider the impact of some of these SDoH on adherence in more detail. Approximately 1 in 10 US adults doesn’t have health insurance. Lack of health insurance alone impacts a person’s ability to access quality healthcare services, afford prescribed medication, and adhere to recommended dosages accordingly.

A retrospective analysis of a large pharmacy claims database found that out of more than ​​200,000 patients treated for diabetes with non-insulin medications, only 69% were adherent. The SDoH variables associated with adherence were older age, male sex, higher education, and higher income.

A systematic review exploring the relationship between SDoH and medication adherence found that food insecurity and housing stability were solid and consistent predictors of medication adherence across many studies.

Another widely-studied factor that predisposes a person to medication non-adherence is their geographical location. It establishes other non-medical factors that influence adherence, including lack of access to life-saving resources like food, security, transportation, digital tools and internet, education, housing, social capital, and more.

Considerable evidence suggests that people in high-income or affluent neighborhoods are more likely to adhere to treatment plans. A study on 749 Mexican-Americans treated for diabetes found that patients in poor communities were 60% more likely to not adhere to prescriptions than patients who stayed in affluent neighborhoods.

Medication cost is another primary barrier that prevents people—up to 20% of the U.S. population—from adhering to a treatment plan. A study found that people with diabetes who discussed cost-effective medication options with their healthcare provider were less likely to engage in cost-related non-adherence. The researchers highlighted the impact of discussing cost-related barriers to medication adherence between patients and providers.

Another study found that social support consistently increased medication adherence and recommended that family and friends be involved in the medication process, from purchasing to administering medication, for greater medication adherence.

Looking down the list above, it’s easy to imagine how each might have an outsized impact on medication adherence. Culture - how much does the patient trust medical providers? Transportation - how hard is it for the patient to get to a pharmacy to pick up their medication? Digital literacy - how well is the patient able to use digital tools to do things like set up medication delivery or set up automatic refills?

What are the barriers to addressing SDoH?

Three significant barriers impact the utilization of SDoH in driving better medication outcomes:

  1. Insufficient data

  2. Lack of access to digital tools

  3. Lack of expertise addressing SDoH

Insufficient data: There currently isn't enough available data to measure SDoH in patients. Researchers and healthcare systems still rely on administrative health care claims databases to measure medication adherence, which don’t adequately reflect patients’ living conditions.

Lack of access to digital tools: Digital literacy and the ability to access the internet have been described as the “super social determinants of health” because they influence health outcomes and address other SDoH that act as barriers to accessing quality healthcare and achieving optimal health.

Yet, advancements in digital technologies and internet connectivity may also widen health inequity in disadvantaged populations. 13% of U.S. adults do not use the Internet—with 19% due to cost reasons. 39% of rural areas don’t have access to reliable broadband internet service. This lack of internet service may hinder people from accessing telemedicine providers, electronic health records, patient portals, medication reminder apps, remote monitoring devices, and other mobile health technologies that improve health and medication outcomes.

Lack of expertise addressing SDoH: Finally, healthcare providers may feel ill-equipped to address SDoH variables that impact medication outcomes because it falls outside their medical expertise. It may not have been a significant part of their training or gets pushed to the side due to other priorities.

Building SDoH into Patient Engagement

Interventions and tools that aim to address health inequities and improve medication outcomes must consider SDoH variables that impact member outcomes.

At WithMe, we collect SDoH data from members in addition to pharmacy, medical, and lab data and identify SDoH barriers to medication outcomes.

When members register for our app, we assess the degree to which they identify with statements that reflect their living conditions.

  • I sometimes have difficulty affording my medications.

  • Finding time to get to the doctor’s office prevents me from getting my medications refilled on time.

  • Sometimes I take my medications less than my doctor prescribed.

  • I have difficulty getting to and from the pharmacy to pick up my medications.

  • I feel like some of my medications do more harm than good.

We then surface this data for our Medication Guides, so they know the barriers that may hinder adherence and can create an inclusive and empathetic approach in every member interaction.

Two-thirds of patients who participate in cost-related non-adherence don’t inform their healthcare providers. In turn, healthcare providers may not even be aware of their patients’ adherence issues. At WithMe, we try to proactively address this issue among our members by using the SDoH built into our database to predict which members may be at risk for suboptimal medication outcomes and proactively providing them the support they need through our app and Medication Guides.

Because we are aware of how digital tools may widen health inequities, we adopt a digitally-inclusive method when using digital tools to promote better member outcomes. Our Medication Guides meet members where they are - engaging via our mobile app, phone, or text, and they work closely with members to ensure they have tools they are comfortable with to manage their medications.

Fortunately, SDoH have been in the spotlight lately. More and more ecosystem participants are acknowledging their importance to healthcare outcomes and pushing for change accordingly, whether it’s updated provider training, context-sensitive employee benefits, or outcomes research.

At WithMe, we’re proud to be focused on improving medication adherence using SDoH, and we’re doing our part to address the barriers for others to do the same - collecting SDoH and outcomes data, providing accessible digital tools to patients, and equipping providers with the tools and knowledge they need to deliver care in an SDoH context.