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HISPANIC MEDICATION ADHERENCE STUDY
HISPANIC MEDICATION ADHERENCE | 1
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
6RPH�RI�WKH�NH\�¿QGLQJV�ZH�FDQ�GUDZ�IURP�RXU�UHVHDUFK�DUH�WKH�IROORZLQJ ...................................................................................................... 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
6HFWLRQ�)��)XO¿OOPHQW .......................................................................................................................................................................................... 35
Section G: Adherence ........................................................................................................................................................................................ 36
REFERENCES ....................................................................................................................................................................................................... 39
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HISPANIC MEDICATION ADHERENCE | 2
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
FRPSOLDQFH� DPRQJ� +LVSDQLFV�� EXW� WKHUH� LV� VWLOO� YHU\� SRRU� XQGHUVWDQGLQJ� RI� ZK\� +LVSDQLFV� GR� QRW� ¿OO� DQG�RU� DGKHUH� WR� WKHLU�medication condition management protocols.
Objectives: The overall objective of the study was to increase our understanding of how this increasingly dominant demographic
JURXS�XVH�DQG�DGKHUH�WR�PHGLFDWLRQ�SURWRFROV��6SHFL¿F�REMHFWLYHV�ZHUH�WR������*DLQ�D�EHWWHU�XQGHUVWDQGLQJ�RI�PHGLFDWLRQ�DGKHUHQFH�DPRQJ�+LVSDQLFV������2EWDLQ�D�GHHSHU�XQGHUVWDQGLQJ�RI�WKH�ZD\V�LQ�ZKLFK�ODQJXDJH�GHWHUPLQHV�KRZ�+LVSDQLFV�DUH�HGXFDWHG�DERXW�DQG�XVH�SUHVFULEHG�PHGLFDWLRQV������(OLFLW�UHFRPPHQGDWLRQV�IURP�VXEMHFW�PDWWHU�H[SHUWV�DV�ZHOO�DV�+LVSDQLFV�WKHPVHOYHV�RQ�KRZ�WR�LQFUHDVH�PHGLFDWLRQ�DGKHUHQFH�DQG�����3URSRVH�SUDFWLFDO�DSSURDFKHV�WR�WUDQVODWLQJ�WKHVH�LQVLJKWV�LQWR�DFWLRQDEOH�LQWHUYHQWLRQV��
Design and Methodologies: 7KH�+LVSDQLF�0HGLFDWLRQ�6WXG\�UHOLHG�RQ�WKUHH�NH\�VRXUFHV�RI�LQIRUPDWLRQ������$�OLWHUDWXUH�UHYLHZ�XVLQJ�KHDOWK�DQG�PHGLFDO�SXEOLFDWLRQV������.H\�LQIRUPDQW�LQWHUYLHZV�ZLWK�VXEMHFW�PDWWHU�H[SHUWV�LQ�WKH�DUHD�RI�+LVSDQLF�KHDOWK�DQG�����$Q�RQOLQH�VXUYH\�¿HOGHG�WR�+ROD'RFWRU¶V�GDWDEDVH�RI�RYHU�RQH�PLOOLRQ�+LVSDQLF�KHDOWK�VHHNHUV�UHVLGLQJ�LQ�WKH�8�6��DQG�3XHUWR�5LFR��
Findings and Results from Literature Review and Key Informant Interviews:�7KH�¿QGLQJV�IURP�WKH�OLWHUDWXUH�UHYLHZ�DQG�NH\�informant interviews offered a number of common insights and the barriers to good medication adherence. Among these were that:
+LVSDQLFV�WHQG�WR�³ZDLW´� WR�EULQJ�WKHPVHOYHV�RU� WKHLU� IDPLO\�PHPEHUV�WR�VHH�D�GRFWRU��RIWHQ�WU\LQJ�DOWHUQDWLYH�QDWXUDO�DSSURDFKHV�¿UVW��ORZ�KHDOWK�OLWHUDF\�KDV�D�QHJDWLYH�LPSDFW�RQ�KHDOWK�VHHNLQJ�DQG�DGKHUHQFH��YLVLWV�WR�GRFWRUV�DUH�DYRLGHG�EHFDXVH�HPSOR\PHQW�LV�PRUH�OLNHO\�WR�EH�KRXUO\�ZDJH�EDVHG�DQG�LI�WKH\�DUHQ¶W�ZRUNLQJ��WKH\�DUHQ¶W�HDUQLQJ�PRQH\��WKHUH�LV�D�ORZ�XQGHUVWDQGLQJ�RI�KRZ�prescribed medications work or what they are for and how they are to be taken, all leading to distrust they will work and lower
DGKHUHQFH��WKHUH�LV�D�JUHDWHU�FRQFHUQ�DERXW�VLGH�HIIHFWV�ZLWK�SUHVFULEHG�PHGLFDWLRQV�DPRQJ�+LVSDQLFV�FRPSDUHG�WR�QRQ�+LVSDQLF�ZKLWHV�� FRVW� RI� FRSD\V�FDQ�EH�D� VHULRXV�GHWHUUHQW� IRU� ORZHU� LQFRPH�+LVSDQLFV��5HJDUGLQJ� ³ZKDW�ZRUNV´� WR� LQFUHDVH�DGKHUHQFH��WDFWLFV�LQFOXGHG��KRPH�YLVLWV�E\�OD\�KHDOWK�ZRUNHUV��FRQGXFWLQJ�³VKRZ�DQG�WHOO´�VHVVLRQV�ZLWK�+LVSDQLF�SDWLHQWV��ZKHUH�WKH�SDWLHQW�RU�FDUHWDNHU�LV�PDGH�WR�KDQGOH�HDFK�PHGLFDWLRQ�DQG�WHOO�WKH�SURYLGHU�ZKDW�HDFK�LV��KRZ�LW�LV�XVHG�DQG�ZKDW�LW�LV�IRU��UHPLQGHUV��LQFOXGLQJ�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
3XHUWR�5LFR�DQG�����RI�ZKRP�ZHUH�LQ�WKH�8QLWHG�6WDWHV��)LIW\�RQH�SHUFHQW�ZHUH�EHWZHHQ����DQG����\HDUV�RI�DJH�����SHUFHQW�RI�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,
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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
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HISPANIC MEDICATION ADHERENCE | 3
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
RU�SRRU�DGKHUHUV��7KH�WRS�UHDVRQV�IRU�QRW�WDNHQ�RQHV�PHGLFDWLRQV�ZHUH��,�IRUJHW�����SHUFHQW���,�IHOW�EHWWHU�����SHUFHQW���KLJK�FRVW�����SHUFHQW���2QOLQH�LQIRUPDWLRQ��HPDLO�DQG�WH[W�PHVVDJLQJ�ZHUH�WKH�WRS�WKUHH�WKLQJV�+LVSDQLFV�IHOW�ZRXOG�KHOS�WKHP�UHPHPEHU�WR�WDNH�PHGLFDWLRQV��7KH�WRS�¿YH�ZD\V�WKDW�SHRSOH�UHPHPEHUHG�WR�WDNH�WKHLU�PHGLFDWLRQV�ZHUH��SDLQ�IHHOLQJ�ZRUVH��KDYLQJ�D�URXWLQH��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.
�� 3DLULQJ�PHGLFDWLRQ�¿QDQFLDO�DVVLVWDQFH�SURJUDPV�ZLWK�LQIRUPDWLRQ�UHJDUGLQJ�FRQGLWLRQV�VR�WKDW�SDWLHQWV�FDQ�DFFHVV�information and understand how to use their medication.
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HISPANIC MEDICATION ADHERENCE | 4
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��$Q�HVWLPDWHG�HLJKW�LQ����XQLQVXUHG�+LVSDQLFV�TXDOL¿HG�IRU�0HGLFDLG��WKH�&KLOGUHQ¶V�+HDOWK�,QVXUDQFH�3ODQ��&+,3��RU�ORZHU�FRVWV�RQ�PRQWKO\�SUHPLXPV�WKURXJK�WKH�+HDOWK�,QVXUDQFH�0DUNHWSODFH��6LQFH�WKH�SDVVDJH�RI�WKH�$IIRUGDEOH�&DUH�$FW������PLOOLRQ�+LVSDQLFV��DJHV��������KDYH�JDLQHG�KHDOWK�LQVXUDQFH�FRYHUDJH��ORZHULQJ�WKH�XQLQVXUHG�UDWH�DPRQJ�+LVSDQLFV�E\�����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
WUHDWPHQWV�DOVR�VKRZ�VLJQL¿FDQWO\�ORZHU�FRPSOLDQFH�ZLWK�PHGLFDWLRQ�UHJLPHQV�WKDQ�QRQ�+LVSDQLF�ZKLWHV��
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
WKHUH� LV�VWLOO� YHU\�SRRU�XQGHUVWDQGLQJ�RI�ZK\�+LVSDQLFV�GR�QRW�¿OO� WKHLU�SUHVFULSWLRQV�DQG�RU�DGKHUH� WR� WKHLU�PHGLFDWLRQ�FRQGLWLRQ�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
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HISPANIC MEDICATION ADHERENCE | 5
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 ¿HOGHG�WR�+ROD'RFWRU¶V�GDWDEDVH�RI�RYHU�RQH�PLOOLRQ�+LVSDQLF�KHDOWK�VHHNHUV�UHVLGLQJ�LQ�WKH�U.S. and Puerto Rico
,Q�WKLV�UHSRUW��ZH�LQFOXGH�WKH�FRPSUHKHQVLYH�¿QGLQJV�IURP�WKHVH�WKUHH�DSSURDFKHV��$�YHUVLRQ�RI�WKH�VWXG\�UHVXOWV�ZLOO�EH�SXEOLVKHG�DV�D�VKRUWHU�ZKLWH�SDSHU�DV�ZHOO�DV�LQ�DQ�DFDGHPLF��SHHU�UHIHUHQFHG�MRXUQDO�DUWLFOH��IRUWKFRPLQJ���
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 MOBILEUntil 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
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HISPANIC MEDICATION ADHERENCE | 6
Instrument Development:� 7KH� VXUYH\� LQVWUXPHQW� ZDV� EDVHG� RQ� EHVW� SUDFWLFHV� LQ� WKH�PHGLFDWLRQ� DGKHUHQFH� ¿HOG�� 7KH� RQOLQH�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
SURYLGHG�LQSXW�RQ�WKH�VXUYH\�TXHVWLRQ�VHW��7KH�¿QDO�VXUYH\�FRQWDLQHG�TXHVWLRQV�RQ�GHPRJUDSKLFV��KHDOWK�FRQGLWLRQV��PHGLFDWLRQ�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 $10 Amazon gift card. The survey was
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Analysis: )UHTXHQFLHV� WDEOHV� ZHUH� JHQHUDWHG� DQG� VWUDWL¿HG� E\� UHVLGHQFH� �3XHUWR� 5LFR� YV�� 8�6�� PDLQODQG��� 'LIIHUHQFHV� ZHUH�GHWHUPLQHG�XVLQJ�FKL�VTXDUH�DW�WKH�S������VLJQL¿FDQFH�OHYHO��
PROVIDER KEY INFORMANT INTERVIEW RESULTS
Three physicians who regularly care for Hispanic patients participated in the in-depth interviews:
• Dr. Eduardo Montana. Pediatric cardiologist and current chair of the Hispanic Health Coalition of Georgia
• Dr. Flavia Mercado. A pediatrician and former chair of the Hispanic Health Coalition of Georgia
• Dr. Ken Dominguez��$�GLUHFWRU�RI�+,9�$,'6�DW�WKH�&HQWHUV�IRU�'LVHDVH�&RQWURO�DQG�3UHYHQWLRQ�DQG�FKDLU�RI�WKH�CDC Hispanic employees working group
7KHVH�VXEMHFW�PDWWHU�H[SHUWV�SURYLGHUV�ZHUH�LQWHUYLHZHG�DERXW�WKH�EDUULHUV�WR�PHGLFDWLRQ�DGKHUHQFH�DPRQJ�+LVSDQLFV�DQG��PRUH�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.
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HISPANIC MEDICATION ADHERENCE | 7
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
�� (YHQ�LI�WKH�GRFWRU�VSHDNV�6SDQLVK��WKH\�VWLOO�RIWHQ�GRQ¶W�XQGHUVWDQG�ZKDW�WKH�GRFWRU�LV�VD\LQJ��,W�LV�PRUH�WKDQ�ODQJXDJH��LW�LV�also “health literacy.”
PERSISTENCE
�� 5H¿OOV�±�WKH\�XVXDOO\�¿OO�WKH�¿UVW�VFULSW��EXW�WKHQ�GRQ¶W�UH¿OO�LW��
• 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
�� 6FKRROV�FDQ�PDNH�WKH�SURFHVV�HYHQ�PRUH�FRPSOLFDWHG��7KH�GRFWRU�DQG�IDPLO\�QHHG�WR�VXEPLW�OHWWHUV�DQG�KDYH�WR�EH�LGHQWL¿HG��so sometimes they just want to avoid the whole situation by not reporting asthma to the school.
�� $VWKPD�LV�WKH�ELJJHVW�FKURQLF�SUREOHP�ZLWK�FKLOGUHQ��:H��GRFWRUV��VWDUW�E\�WHDFKLQJ�WKH�SDUHQWV��EXW�³HYHQWXDOO\�ZH�QHHG�WR�teach the children.”
�� ³:H�SURYLGHUV�WKLQN�WKDW�FRPSOLDQFH�LV�WKH�PRVW�LPSRUWDQW��EXW�WKH\��WKH�SDUHQWV�DQG�NLGV��DUH�GHDOLQJ�ZLWK�ORWV�RI�RWKHU�WKLQJV��like just getting to school.”
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HISPANIC MEDICATION ADHERENCE | 8
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.
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HISPANIC MEDICATION ADHERENCE | 9
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
V�KH�LV�SUHVFULELQJ�DUH�DIIRUGDEOH��RWKHUZLVH��WKH�SDWLHQW�ZRQ¶W�¿OO�RU�UH¿OO�WKHP��
• 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.”
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WHAT ELSE WORKS?
�� +RPH�YLVLWV�E\�OD\�KHDOWK�ZRUNHUV��WKH\�FDQ�FKHFN�WR�PDNH�VXUH�WKDW�WKH�PHGV�DUH�VWRUHG�SURSHUO\��UHIULJHUDWHG�� 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.
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HISPANIC MEDICATION ADHERENCE | 10
SURVEY RESULTS
Study Population: A total of 1,712 Hispanic consumers
completed the survey. Approximately half of the participants
�Q �����ZHUH�IURP�3XHUWR�5LFR��ZKLOH�WKH�UHVW�ZHUH�OLYLQJ�LQ�WKH�8QLWHG�6WDWHV��Q ������7KH�VWDWHV�ZKHUH�WKH\�OLYHG�ZHUH�WKH�WRS�¿YH�+LVSDQLF�VWDWHV��&DOLIRUQLD��)ORULGD��,OOLQRLV��1HZ�York and Texas.
7KH� PDMRULW\� RI� UHVSRQGHQWV� ZHUH� ZRPHQ� ���� SHUFHQW���The age distribution of the respondents is presented in the
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-
language health websites and a free prescription medication
program. It is not surprising, then, that most spoke only
Spanish at home, or a mix of Spanish and English. Less
than one percent spoke only English at home. As expected,
D� VLJQL¿FDQWO\� KLJKHU� SHUFHQWDJH� RI� UHVSRQGHQWV� OLYLQJ� LQ�Puerto Rico spoke only Spanish at home. In a separate
question, 90 percent of participants indicated they prefer to
receive health information in Spanish.
WHICH LANGUAGES DO YOU SPEAK AT HOME?*
United States Puerto Rico Total
English and Spanish equally169 107 276
22% 12% 17%
More Spanish than English309 344 653
40% 40% 40%
More English than Spanish18 6 24
2% 1% 2%
Another language5 0 5
1% 0% 0%
Only Spanish260 405 665
34% 47% 41%
Only English4 2 6
1% <1% <1%
TOTAL 414 408 822
54%
12%
11%
8%
8%
4%
3%
Residence
Puerto Rico
Florida
Other
California
Texas
Illinois
New York
65+5%
5-6417%
45-5426% 35-44
25%
25-3422%
15-245%
Age Distribution
�Q ������
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HISPANIC MEDICATION ADHERENCE | 11
Health Insurance: Over three-quarters of the sample
reported having health insurance. Insurance coverage
ZDV�VLJQL¿FDQWO\�KLJKHU�IRU�WKRVH�OLYLQJ�LQ�3XHUWR�5LFR����� SHUFHQW�� WKDQ� WKRVH� OLYLQJ� LQ� WKH�PDLQODQG� 8�6������ SHUFHQW��� 7KH� SHUFHQWDJH� RI� UHVSRQGHQWV� RQ�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
$IIRUGDEOH�&DUH�$FW�H[FKDQJHV��NQRZQ�WR�+LVSDQLFV�DV� ³2EDPDFDUH´��� ZKLOH� WKRVH� OLYLQJ� LQ� 3XHUWR� 5LFR�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.
United States Puerto Rico Total
Medicaid79 161 240
20% 22% 21%
Medicare64 118 182
16% 16% 16%
Insurance through an employer or spouse’s employer145 258 403
37% 35% 35%
Private insurance through Obamacare69 43 112
18% 6% 10%
Private insurance bought directly through a private company37 167 204
9% 23% 18%
None335 58 393
44% 7% 24%
TOTAL 762 862 1,624
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HISPANIC MEDICATION ADHERENCE | 12
MEDICAL CONDITIONS AND HISTORY
1HDUO\�DOO�RI�WKH�UHVSRQGHQWV�KDG�RQH�RU�PRUH�PHGLFDO�FRQGLWLRQV�DQG�ZHUH�WDNLQJ�RQH�RU�PRUH�SUHVFULSWLRQ�PHGLFDWLRQV���6HH�EHORZ���
Number of Medical Conditions and Number of Medications Being Taken
Number of Medical Conditions0 12%
1 18%
2 17%
3 17%
4 11%
5 7%
6 to 10 13%
11+ 3%
Number of Medications Being Taken0 14%
1 22%
2 19%
3 14%
4 9%
5 8%
6 to 10 12%
11+ 3%
Number of Medications Prescribed0 13%
1 19%
2 16%
3 16%
4 10%
5 8%
6 to 10 13%
11+ 3%
86%�Q ������
have at least one medical condition and take at least one medication
7KH�PRVW�SUHYDOHQW�PHGLFDO�FRQGLWLRQV�IRU�ZKLFK�SDUWLFLSDQWV�ZHUH�WDNLQJ�PHGLFDWLRQV�ZHUH�KLJK�EORRG�SUHVVXUH��SDLQ��DFLG�UHÀX[�and diabetes. Subjects living in Puerto Rico reported higher usage of medications for conditions.
Which Health Conditions Do You Take Medications For?
0%
10%
20%
30%
40%
50%
8%
18%
15%
20%
23%22%
0%1%1%
19%
22%20%
31%
37%34%
19%
29%
23%
5% 5% 5%
9%
18%
14%
1% 1% 1%
30%
43%
37%
14%
20%
17%
8%
20%
14%
22%24%
23%
Asthma High Cholesterol
COPD Diabetes Pain Acid Reflux Anemia Arthritis Birth Control High Blood Pressure
Mental Health/Depression
Hypo-/Hyperthyroidism
Other
■ United States ■ Puerto Rico ■ Total
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HISPANIC MEDICATION ADHERENCE | 13
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.
MMAS Scores
0 1 2 3 4
31%
14%
22% 21%
25%23% 22%
24% 23%
17%
23%20%
9%
15%12%
0%
5%
10%
15%
20%
25%
30%
35%
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.
United States Puerto Rico Total
Have you ever forgotten to take medication for your condition?
No330 248 57843% 29% 35%
Yes441 618 1,05957% 71% 65%
TOTAL 771 866 1,637
Have you ever had problems remembering to take your medication?
No503 482 98565% 56% 60%
Yes265 381 64635% 44% 40%
TOTAL 768 863 1,631
When you feel better, do you sometimes stop taking your medications?
No463 516 979
60% 60% 60%
Yes305 349 65440% 40% 40%
TOTAL 768 865 1,633
If you feel worse when taking your medication, do you stop taking it?
No486 475 96163% 55% 59%
Yes286 390 67637% 45% 41%
TOTAL 772 865 1,637
■ United States ■ Puerto Rico ■ Total
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HISPANIC MEDICATION ADHERENCE | 14
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?*
United States Puerto Rico Total
No414 510 924
58% 64% 61%
Yes, I’m in a program sponsored by a pharmaceutical company9 7 16
1% 1% 1%
Yes, I’m in a program sponsored by a pharmacy44 22 66
6% 3% 4%
Yes, I receive a medication discount through the clinic I go to40 5 45
6% 1% 3%
Yes, I use a medication discount card169 221 390
24% 28% 26%
Yes, I’m in a different program that decreases my medication costs38 33 71
5% 4% 5%
TOTAL 714 798 1,512
OF THOSE WHO USE MEDICATION DISCOUNT CARDS, ARE THEY UNIVISION CARDS OR OTHER CARDS?
United States Puerto Rico Total
Other40 26 66
19% 10% 14%
Univision169 235 404
81% 90% 86%
TOTAL 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.
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HISPANIC MEDICATION ADHERENCE | 15
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
H[SODLQV�WKLV�VLJQL¿FDQW�GLIIHUHQFH��
HAVE YOU EVER FELT DISCONNECTED FROM YOUR DOCTOR BECAUSE OF YOUR CULTURE?
United States Puerto Rico Total
No569 755 1324
77% 92% 85%
Yes170 63 233
23% 8% 15%
TOTAL 739 818 1,557
,QWHUHVWLQJO\��ZKHQ�SDUWLFLSDQWV�ZHUH�DVNHG� ³+RZ�RIWHQ�GR�\RX�KDYH�GLI¿FXOW\�FRPPXQLFDWLQJ�ZLWK�\RXU�GRFWRU"�´� WKH� UDWHV�ZHUH�similar among respondents in the U.S. and Puerto Rico.
HOW OFTEN DO YOU HAVE DIFFICULTY COMMUNICATING WITH YOUR DOCTOR?
United States Puerto Rico Total
Usually48 35 83
6% 4% 5%
Sometimes149 143 292
20% 17% 18%
Once in a while143 137 280
19% 16% 17%
1HYHU�5DUHO\425 536 961
56% 63% 60%
TOTAL 765 851 1,616
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HISPANIC MEDICATION ADHERENCE | 16
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�Q ������
■ United States ■ Puerto Rico
Doctor Pharmacist Nurse
78%72%
13%
24%
2% 1% 2% 1%5% 3% 1% 1%
Family Member Health Promoter Friend0%
10%
20%
30%
40%
50%
60%
70%
80%
ADHERENCE
Overwhelmingly, the most common reason participants did not take their medication was because they forgot.
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HISPANIC MEDICATION ADHERENCE | 17
When You Don’t Take Your Medication, What Is the Main Reason You Don’t Take It?
■ United States ■ Puerto Rico ■ Total
0%
10%
20%
30%
40%
50%
Financial UHDVRQV�
too expensive
It’s too GLI¿FXOW�WR�go to the pharmacy
I feel better
I feel worse
Need to JHW�D�UH¿OO
I don’t understand why I have to take it
I forget I don’t need it
anymore
Other 1�$� �,�DOZD\V�WDNH�WKHP�
AFFORDABILITY
1HDUO\����SHUFHQW�RI�WKH�VXUYH\�SDUWLFLSDQWV�IHOW�WKDW�WKHLU�PHGLFDWLRQV�ZHUH�HLWKHU�³XQDIIRUGDEOH´�����SHUFHQW��RU�³YHU\�XQDIIRUGDEOH´�����SHUFHQW���
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
DQVZHULQJ�³\HV´�WR�FORVHG�HQGHG�TXHVWLRQV�DERXW�VSHFL¿F�WDFWLFV�DUH�SUHVHQWHG�LQ�WKH�JUDSKLF�EHORZ��
WAYS TO REMEMBER TO TAKE MEDICATION: PERCENT ANSWERING “YES”�Q ������
ONLINE INFORMATION
United States 87%Puerto Rico 90%
EMAIL REMINDERS
United States 56%Puerto Rico 57%
TEXT REMINDERS
United States 59%Puerto Rico 60%
@
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HISPANIC MEDICATION ADHERENCE | 18
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,
DODUPV�FDOHQGDUV�DQG�KDYLQJ�WKH�SLOOV�LQ�D�SODFH�ZKHUH�WKH\�FDQ�HDVLO\�EH�VHHQ��
WHAT HELPS YOU REMEMBER YOUR MEDICATION?
Number of Mentions
3DLQ�DQG�RU�IHHOLQJ�ZRUVH 110
Have a certain routine 108
$ODUP�FDOHQGDU�UHPLQGHU 90
6HHLQJ�WKH�PHGLFDWLRQV�SXWWLQJ�WKHP�ZKHUH�WKH\�FDQ�EH�VHHQ 74
.QRZLQJ�LW¶V�LPSRUWDQW�IRU�P\�KHDOWK�ZDQWLQJ�WR�IHHO�EHWWHU 71
)DPLO\�LQGLYLGXDO�UHPLQGV�PH 38
Pillbox 27
2WKHU�UHPLQGHUV��FDOOV��HPDLOV��ZULWWHQ��WH[WV��SKRQH�DSSV� 26
Other 12
%HWWHU�¿QDQFLDO�DFFHVV 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 whateverLOOQHVV�RQH�LV�VXHULQJ�IURP�DQG�DYRLG�VRPHWKLQJ�PRUH�VHULRXV�RU�FDXVLQJ�WKH�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.
ȏ��0\�VRQ�LV�P\�UHDVRQ�IRU�VWD\LQJ�KHDOWK\��+H�LV�RQO\�ȴYH�\HDUV�ROG��DQG�Ζ�DP�D�widow, so it’s just us.
• I am very forgetful when it comes to taking medications, but if someonereminds me, it helps me to remember.
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HISPANIC MEDICATION ADHERENCE | 19
7KH�¿QDO�TXHVWLRQ�DVNHG�WKH�SDUWLFLSDQWV�ZDV�³:KDW�ZRXOG�KHOS�+LVSDQLFV�WDNH�WKHLU�PHGLFDWLRQ"´�,Q�RWKHU�UHVHDUFK��ZH�KDYH�IRXQG�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
URXWLQHV�ZHUH�DOVR�PHQWLRQHG��DV�WKH\�ZHUH�LQ�WKH�SUHYLRXV�TXHVWLRQ��6RPH�VXJJHVWHG�WKDW�EHWWHU�¿QDQFLDO�DVVLVWDQFH�DQG�DFFHVV��H�J���ORZHU�SULFHV��ZRXOG�EH�KHOSIXO��1RWDEO\��RQO\�D�VPDOO�QXPEHU�RI�SHRSOH�IHOW�WKDW�PRUH�LQIRUPDWLRQ�LQ�6SDQLVK�RU�6SDQLVK�VSHDNLQJ�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 Mentions0RUH�HGXFDWLRQ�LQIRUPDWLRQ�UHJDUGLQJ�WKH�FRQGLWLRQ�DQG�PHGLFDWLRQ 168
$ODUPV�UHPLQGHUV�WKURXJK�DODUPV�RU�HPDLO 71
%HWWHU�DFFHVV�¿QDQFLDO�KHOS�WR�EX\�PHGLFDWLRQV 63
Establishing a routine 57
7H[W�PHVVDJLQJ�DSSOLFDWLRQV 37
Reminders from family members 28
Other 20
6SDQLVK�ODQJXDJH�PDWHULDOV�LQIRUPDWLRQ 7
2WKHU�ZULWWHQ�WHOHYLVLRQ�UHPLQGHUV 6
%HWWHU�GRFWRUV�GRFWRUV�ZKR�VSHDN�6SDQLVK 5
Pillbox 4
REPRESENTATIVE QUOTATIONS WHEN ASKED “WHAT WOULD HELP HISPANICS TAKE THEIR MEDICATION?”ȏ��%HLQJ�EHWWHU�LQIRUPHG�DQG�NQRZLQJ�WKH�EHQHȴWV�DVVRFLDWHG�ZLWK�WDNLQJ�WKHP��
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 thathelps 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.
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HISPANIC MEDICATION ADHERENCE | 20
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.
�� /LNH�QRQ�+LVSDQLFV��XQGHUVWDQGLQJ�WKHVH�FRQGLWLRQV�DQG�WKH�SUHVFULEHG�WUHDWPHQWV�FDQ�EH�GLI¿FXOW��0RVW�GR�QRW�WDNH�WKHLU�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
WKH�PHGLFDWLRQV�WKHPVHOYHV´�ZDV�VRUHO\�QHHGHG�DQG�WKDW�KHOSLQJ�SHRSOH�XQGHUVWDQG�WKHVH�EHWWHU�FRXOG�VLJQL¿FDQWO\�LQFUHDVH�medication adherence.
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HISPANIC MEDICATION ADHERENCE | 21
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.
�� 3DLU�PHGLFDWLRQ�¿QDQFLDO�DVVLVWDQFH�SURJUDPV�ZLWK�LQIRUPDWLRQ�UHJDUGLQJ�FRQGLWLRQV�VR�WKDW�SDWLHQWV�FDQ�DFFHVV�LQIRUPDWLRQ�and understand how to use their medication.
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HISPANIC MEDICATION ADHERENCE | 22
ABOUT THE AUTHORS
ABOUT HOLADOCTOR
+ROD'RFWRU�,QF���www.holadoctor.net��LV�WKH�OHDGLQJ�+LVSDQLF�KHDOWK�PDUNHWLQJ�FRPSDQ\�LQ�WKH�8�6��+ROD'RFWRU�RZQV�DQG�RSHUDWHV�WKH�PRVW�SRSXODU�6SDQLVK�ODQJXDJH�KHDOWK�FDUH�ZHEVLWH�RQOLQH��www.holadoctor.com��DQG�LV�WKH�H[FOXVLYH�KHDOWK�SDUWQHU�WR�8QLYLVLRQ�Interactive. The company provides strategic consulting, marketing solutions and culturally relevant programs to health plans,
SURYLGHUV��JRYHUQPHQWDO�DJHQFLHV�DQG�RWKHU�KHDOWK�FDUH�HQWLWLHV��+ROD'RFWRU�KDV�RI¿FHV�LQ�$WODQWD��0LDPL�DQG�0H[LFR�&LW\��
ABOUT ENVISIONRX
(QYLVLRQ5[2SWLRQV� LV�D�KHDOWK�FDUH�DQG�SKDUPDF\�EHQH¿W�PDQDJHPHQW��3%0��FRPSDQ\�KHDGTXDUWHUHG� LQ�7ZLQVEXUJ��2KLR��:H�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:�'U��6FKURHGHU�LV�WKH�H[HFXWLYH�93�DQG�&KLHI�+HDOWK�2I¿FHU�DW�+ROD'RFWRU�,QF��+H�LV�DOVR�DQ�DGMXQFW�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,
PXQLFLSDOLWLHV��QRQSUR¿W�RUJDQL]DWLRQV�DQG�HPSOR\HUV�� WR�GHOLYHU� YDOXDEOH�VHUYLFHV� WR�PRUH� WKDQ����PLOOLRQ� OLYHV��3ULRU� WR� MRLQLQJ�Envision in 2009, Ms. Alaoui held executive roles with American Express in Finance, Operations, Tax, Treasury and Merchant
6HUYLFHV�� %HIRUH�$PHULFDQ� ([SUHVV�� VKH� ZRUNHG� IRU� WKH� 1DWLRQDO� &RXQFLO� RQ� &RPSHQVDWLRQ� ,QVXUDQFH� �1&&,�� RYHUVHHLQJ� WKH�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.
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HISPANIC MEDICATION ADHERENCE | 23
CONTACTS
Dr. Dirk G. SchroederPrincipal Investigator
(93��&KLHI�+HDOWK�2I¿FHUHolaDoctor, Inc.
900 Old Roswell Lakes Parkway, Suite 230
Roswell, Georgia 30075
dschroeder@holadoctor.net
��������������
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HISPANIC MEDICATION ADHERENCE | 24
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*
United States Puerto Rico Total
Female516 649 1165
68% 75% 72%
Male244 212 456
32% 25% 28%
TOTAL 760 861 1,621
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HISPANIC MEDICATION ADHERENCE | 25
AGE
United States Puerto Rico Total
15-2442 39 81
5% 4% 5%
25-34197 171 368
26% 20% 22%
35-44222 191 413
29% 22% 25%
45-54157 270 427
20% 31% 26%
55-64118 156 274
15% 18% 17%
65+34 42 76
4% 5% 5%
TOTAL 770 869 1,639
STATE/TERRITORY RESIDENCE
54%
12%
11%
8%
8%
4%
3%
Puerto Rico
Florida
Other
California
Texas
Illinois
New York
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HISPANIC MEDICATION ADHERENCE | 26
WHICH LANGUAGES DO YOU SPEAK AT HOME?*
United States Puerto Rico Total
English and Spanish equally169 107 276
22% 12% 17%
More Spanish than English309 344 653
40% 40% 40%
More English than Spanish18 6 24
2% 1% 2%
Another language5 0 5
1% 0% 0%
Only Spanish260 405 665
34% 47% 41%
Only English4 2 6
1% <1% <1%
TOTAL 414 408 822
IN WHICH LANGUAGE DO YOU PREFER TO RECEIVE INFORMATION ABOUT YOUR MEDICATIONS?
United States Puerto Rico Total
Spanish675 788 1463
89% 91% 90%
English84 74 158
11% 9% 10%
TOTAL 759 862 1,621
DO YOU CURRENTLY HAVE INSURANCE?**
United States Puerto Rico Total
No335 58 393
44% 7% 24%
Yes427 862 1231
56% 93% 76%
TOTAL 762 862 1,624
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HISPANIC MEDICATION ADHERENCE | 27
FOR THOSE WHO HAVE INSURANCE, WHAT KIND OF INSURANCE?*
United States Puerto Rico Total
Medicaid79 161 240
20% 22% 21%
Medicare64 118 182
16% 16% 16%
Insurance through an employer or spouse’s employer145 258 403
37% 35% 35%
Private insurance through Obamacare69 43 112
18% 6% 10%
Private insurance bought directly through a private company37 167 204
9% 23% 18%
TOTAL 394 747 1141
DOES YOUR INSURANCE COVER YOUR PRESCRIPTION MEDICATIONS?
United States Puerto Rico Total
No67 139 206
16% 18% 17%
Yes346 629 975
84% 82% 83%
TOTAL 413 768 1181
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HISPANIC MEDICATION ADHERENCE | 28
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?
United States Puerto Rico Total
11+15 38 53
2% 4% 3%
Six to 1076 146 222
9% 17% 13%
Five40 95 135
5% 11% 8%
Four66 99 165
8% 11% 10%
Three128 143 271
15% 16% 16%
Two169 143 271
15% 16% 16%
One193 130 323
23% 15% 19%
Zero155 76 231
18% 9% 13%
TOTAL 842 879 1,712
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HISPANIC MEDICATION ADHERENCE | 29
HOW MANY MEDICATIONS ARE YOU CURRENTLY TAKING?
United States Puerto Rico Total
11+9 33 42
1% 4% 2.5%
Six to 1071 134 205
8% 15% 12%
Five36 94 130
4% 11% 8%
Four63 89 152
7% 10% 9%
Three108 132 240
13% 15% 14%
Two181 149 330
22% 17% 19%
One207 173 380
25% 20% 22%
Zero167 66 233
20% 8% 14%
TOTAL 842 870 1,712
For Which Conditions Are You Currently Prescribed Medication? �5HVSRQGHQWV�ZHUH�DEOH�WR�VHOHFW�PRUH�WKDQ�RQH��
■ United States ■ Puerto Rico ■ Total
0%
10%
20%
30%
40%
50%
8%
18%
15%
20%
23%22%
0%1%1%
19%
22%20%
31%
37%34%
19%
29%
23%
5% 5% 5%
9%
18%
14%
1% 1% 1%
30%
43%
37%
14%
20%
17%
8%
20%
14%
22%24%
23%
Asthma High Cholesterol
COPD Diabetes Pain Acid Reflux Anemia Arthritis Birth Control High Blood Pressure
Mental Health/Depression
Hypo-/Hyperthyroidism
Other
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HISPANIC MEDICATION ADHERENCE | 30
SECTION D: MMAS
00$6�2YHUDOO�$YHUDJH���������� 0RGHUDWHO\�DGKHUHQW� MMAS PR: 2.0
MMAS Other: 1.5
MMAS Scores
■ United States ■ Puerto Rico ■ Total
0 1 2 3 4
31%
14%
22% 21%
25%23% 22%
24% 23%
17%
23%20%
9%
15%12%
0%
5%
10%
15%
20%
25%
30%
35%
HAVE YOU EVER FORGOTTEN TO TAKE MEDICATION FOR YOUR CONDITION?**
United States Puerto Rico Total
No330 248 578
43% 29% 35%
Yes441 618 1059
57% 71% 65%
TOTAL 771 866 1,637
HAVE YOU EVER HAD PROBLEMS REMEMBERING TO TAKE YOUR MEDICATION?**
United States Puerto Rico Total
No503 482 985
65% 56% 60%
Yes265 381 646
35% 44% 40%
TOTAL 768 863 1,631
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HISPANIC MEDICATION ADHERENCE | 31
WHEN YOU FEEL BETTER DO YOU SOMETIMES STOP TAKING YOUR MEDICATIONS?
United States Puerto Rico Total
No463 516 979
60% 60% 60%
Yes305 349 654
40% 40% 40%
TOTAL 768 865 1,633
IF YOU FEEL WORSE WHEN TAKING YOUR MEDICATION, DO YOU STOP TAKING IT?**
United States Puerto Rico Total
No486 475 961
63% 55% 59%
Yes286 390 676
37% 45% 41%
TOTAL 772 865 1,637
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HISPANIC MEDICATION ADHERENCE | 32
SECTION E: INITIAL PRESCRIPTION
DO YOU USE A DISCOUNT MEDICATION PROGRAM TO HELP PAY FOR YOUR MEDICATION?*
United States Puerto Rico Total
No414 510 924
58% 64% 61%
Yes, I’m in a program sponsored by a pharmaceutical company9 7 16
1% 1% 1%
Yes, I’m in a program sponsored by a pharmacy44 22 66
6% 3% 4%
Yes, I receive a medication discount through the clinic I go to40 5 45
6% 1% 3%
Yes, I use a medication discount card169 221 390
24% 28% 26%
Yes, I’m in a different program that decreases my medication costs38 33 71
5% 4% 5%
TOTAL 714 798 1,512
OF THOSE WHO USE MEDICATION DISCOUNT CARDS, ARE THEY UNIVISION CARDS OR OTHER CARDS?
United States Puerto Rico Total
Other40 26 66
19% 10% 14%
Univision169 235 404
81% 90% 86%
TOTAL 209 261 470
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HISPANIC MEDICATION ADHERENCE | 33
HOW FREQUENTLY DO YOU TRUST THE INFORMATION THAT YOUR DOCTOR GIVES YOU REGARDING YOUR HEALTH
AND MEDICATION?*
United States Puerto Rico Total
Always295 337 632
40% 42% 41%
Usually289 357 646
40% 44% 42%
Sometimes65 69 134
9% 9% 9%
Once in a while54 34 88
7% 4% 6%
1HYHU�UDUHO\27 12 39
4% 2% 3%
TOTAL 730 809 1,539
HAVE YOU EVER FELT DISCONNECTED FROM YOUR DOCTOR BECAUSE OF YOUR CULTURE?**
United States Puerto Rico Total
No569 755 1324
77% 92% 85%
Yes170 63 233
23% 8% 15%
TOTAL 739 818 1,557
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HISPANIC MEDICATION ADHERENCE | 34
HOW OFTEN DO YOU HAVE DIFFICULTY COMMUNICATING WITH YOUR DOCTOR?
United States Puerto Rico Total
Usually48 35 83
6% 4% 5%
Sometimes149 143 292
20% 17% 18%
Once in a while143 137 280
19% 16% 17%
1HYHU�UDUHO\425 536 961
56% 63% 60%
TOTAL 765 851 1616
WHO WOULD YOU PREFER TO GIVE YOU INFORMATION ABOUT HOW TO TAKE YOUR MEDICATION?*
United States Puerto Rico Total
Friend4 1 5
<1% <1% <1%
Doctor611 620 1231
78% 72% 75%
Nurse12 4 16
2% <1% 1%
Family member16 12 28
2% 1% 2%
Pharmacist102 206 308
13% 24% 19%
Health promoter37 22 59
5% 3% 4%
TOTAL 782 865 1647
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HISPANIC MEDICATION ADHERENCE | 35
SECTION F: FULFILLMENT
HOW OFTEN DO YOU HAVE DIFFICULTY COMMUNICATING WITH YOUR PHARMACIST?*
United States Puerto Rico Total
Always30 15 45
4% 2% 3%
Usually29 25 54
4% 3% 3%
Sometimes112 100 212
14% 12% 13%
Once in a while120 106 226
15% 12% 14%
1HYHU�UDUHO\502 614 1116
63% 71% 68%
TOTAL 793 860 1653
HOW OFTEN DO YOU HAVE DIFFICULTY REFILLING YOUR PRESCRIPTION?
United States Puerto Rico Total
Always23 6 29
3% 1% 2%
Usually30 21 51
4% 2% 3%
Sometimes188 147 265
15% 17% 16%
Once in a while146 161 307
18% 19% 19%
1HYHU�UDUHO\475 524 999
60% 61% 61%
TOTAL 792 859 1651
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HISPANIC MEDICATION ADHERENCE | 36
SECTION G: ADHERENCE
When You Don’t Take Your Medication, What Is the Main Reason You Don’t Take It?
0%
10%
20%
30%
40%
50%
Financial UHDVRQV�
too expensive
It’s too GLI¿FXOW�WR�go to the pharmacy
I feel better
I feel worse
Need to JHW�D�UH¿OO
I don’t understand why I have to take it
I forget I don’t need it
anymore
Other 1�$� �,�DOZD\V�WDNH�WKHP�
HOW AFFORDABLE ARE YOUR PERSONAL MEDICATIONS?*
United States Puerto Rico Total
Very affordable171 119 290
22% 14% 18%
Affordable323 411 734
41% 48% 44%
Unaffordable206 252 458
26% 29% 28%
Very unaffordable95 82 177
12% 10% 11%
TOTAL 795 864 1659
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HISPANIC MEDICATION ADHERENCE | 37
IF YOU READ ADDITIONAL INFORMATION ONLINE ABOUT YOUR CONDITION AND MEDICATION,
WOULD IT HELP YOU TAKE YOUR MEDICATION?
United States Puerto Rico Total
No103 86 189
13% 10% 11%
Yes691 777 1468
87% 90% 89%
TOTAL 794 863 1657
WOULD EMAIL REMINDERS HELP YOU TAKE YOUR MEDICATION?
United States Puerto Rico Total
No351 369 720
44% 43% 44%
Yes442 492 934
56% 57% 56%
TOTAL 793 861 1654
WOULD TEXT REMINDERS HELP YOU TAKE YOUR MEDICATION?
United States Puerto Rico Total
No157 183 340
42% 40% 41%
Yes221 271 492
59% 60% 59%
TOTAL 378 454 832
WHAT USUALLY HELPS YOU REMEMBER TO TAKE YOUR MEDICATION?
Number of Mentions
3DLQ�DQG�RU�IHHOLQJ�ZRUVH 110
Have a certain routine 108
$ODUP�FDOHQGDU�UHPLQGHU 90
6HHLQJ�WKH�PHGLFDWLRQV�SXWWLQJ�WKHP�ZKHUH�WKH\�FDQ�EH�VHHQ 74
.QRZLQJ�LW¶V�LPSRUWDQW�IRU�P\�KHDOWK�ZDQWLQJ�WR�IHHO�EHWWHU 71
)DPLO\�LQGLYLGXDO�UHPLQGV�PH 38
Pillbox 27
2WKHU�UHPLQGHUV��FDOOV��HPDLOV��ZULWWHQ��WH[WV��SKRQH�DSSV� 26
Other 12
%HWWHU�¿QDQFLDO�DFFHVV 2
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HISPANIC MEDICATION ADHERENCE | 38
WHAT WOULD HELP HISPANICS TAKE THEIR MEDICATION?
Number of Mentions
0RUH�HGXFDWLRQ�LQIRUPDWLRQ�UHJDUGLQJ�WKH�FRQGLWLRQ�DQG�PHGLFDWLRQ 168
$ODUPV�UHPLQGHUV�WKURXJK�DODUPV�RU�HPDLO 71
%HWWHU�DFFHVV�¿QDQFLDO�KHOS�WR�EX\�PHGLFDWLRQV 63
Establishing a routine 57
7H[W�PHVVDJLQJ�DSSOLFDWLRQV 37
Family or other person helping them to remember 28
Other 20
6SDQLVK�ODQJXDJH�PDWHULDOV�LQIRUPDWLRQ 7
2WKHU�ZULWWHQ�WHOHYLVLRQ�UHPLQGHUV 6
%HWWHU�GRFWRUV�GRFWRUV�ZKR�VSHDN�6SDQLVK 5
Pillbox 4
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HISPANIC MEDICATION ADHERENCE | 39
REFERENCES
1 U.S. Census Community Survey, 2013.
2 U.S. Census Community Survey, 2013.
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4��++6�2I¿FH�RI�0LQRULW\�+HDOWK��������
5 Colby JA, Wang F, Chhabra J, Perez-Escamilla R. Predictors of medication adherence in an urban Latino community with healthcare disparities. J ,PPLJU�0LQRU�+HDOWK�������$XJ��������������
6���=KDQJ�<��%DLN�6+��5DFH�HWKQLFLW\��GLVDELOLW\�DQG�PHGLFDWLRQ�DGKHUHQFH�DPRQJ�0HGLFDUH�EHQH¿FLDULHV�ZLWK�KHDUW�IDLOXUH��-�*HQ�,QWHUQ�0HG�������$SU��������������
7���=KDQJ�<��%DLN�6+��&KDQJ�&&��.DSODQ�&0��/DYH�-5��'LVDELOLW\��UDFH�HWKQLFLW\�DQG�PHGLFDWLRQ�DGKHUHQFH�DPRQJ�0HGLFDUH�P\RFDUGLDO�LQIDUFWLRQ�VXUYLYRUV��$P�+HDUW�-�������6HS����������������H��
8���/DXIIHQEXUJHU�-&��5RELQVRQ�-*��2UDPDVLRQZX�&��)DQJ�*��5DFLDO�HWKQLF�DQG�JHQGHU�JDSV�LQ�WKH�XVH�RI�DQG�DGKHUHQFH�WR�HYLGHQFH�EDVHG�SUHYHQWLYH�WKHUDSLHV�DPRQJ�HOGHUO\�0HGLFDUH�3DUW�'�EHQH¿FLDULHV�DIWHU�DFXWH�P\RFDUGLDO�LQIDUFWLRQ��&LUFXODWLRQ�������)HE������������������
9 Parada H Jr, Horton LA, Cherrington A, Ibarra L, Ayala GX. Correlates of medication nonadherence among Latinos with type 2 diabetes. Diabetes (GXF�������-XO�$XJ��������������
10 Gaskin DJ, Briesacher BA, Limcangco R, Brigantti BL. Exploring racial and ethnic disparities in prescription drug spending and use among 0HGLFDUH�EHQH¿FLDULHV��$P�-�*HULDWU�3KDUPDFRWKHU�������-XQ�������������
11���)UDQNHQ¿HOG�'/��:HL�,,��$QGHUVRQ�..��+RZHOO�%/��:DOGR�'��6HNVFHQVNL�(��3UHVFULSWLRQ�PHGLFDWLRQ�FRVW�UHODWHG�QRQ�DGKHUHQFH�DPRQJ�0HGLFDUH�&$+36�UHVSRQGHQWV��GLVSDULW\�E\�+LVSDQLF�HWKQLFLW\��-�+HDOWK�&DUH�3RRU�8QGHUVHUYHG�������0D\��������������
12 Lanouette NM, Folsom DP, Sciolla A, Jeste DV. Psychotropic medication nonadherence among United States Latinos: a comprehensive literature UHYLHZ��3V\FKLDWU�6HUY�������)HE���������������GRL����������DSSL�SV�����������5HYLHZ�
13 Hu D, Juarez DT, Yeboah M, Castillo TP. Interventions to increase medication adherence in African-American and Latino populations: a literature UHYLHZ��+DZDLL�-�0HG�3XEOLF�+HDOWK�������-DQ������������
14 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.
15 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.
16 HHS and U.S. Census, 2015.
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