Psychology, Health & Medicine, 2017

VOL. 22, NO. 10, 1217–1223

https://doi.org/10.1080/13548506.2017.1316412

‘A necessary evil’: associations with taking medication and

their relationship with medication adherence
Mieke Kleppea,b,c, Joyca Lacroixc, Jaap Hamb and Cees Middenb
a
Applied Research Centre of Public Affairs, HAN University of Applied Sciences, Nijmegen, The Netherlands;
b
Eindhoven University of Technology, Eindhoven, The Netherlands; cPhilips Research, Eindhoven, The
Netherlands

ABSTRACT ARTICLE HISTORY

Cognitive factors, like beliefs, have been studied extensively as
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Received 19 August 2016

determinants of medication adherence, while affect associated Accepted 21 March 2017
with taking medicines has been studied much less. In the present KEYWORDS
study (N  =  525), we investigated affect by assessing patients’ first Medication; adherence;
associations with taking their medicines. Results showed that these affect; chronic illness; beliefs
associations were related to self-reported medication adherence:
Patients who associated taking medicines with negative affect were
the least adherent, while those associating taking medicines with the
need to take medicines were the most adherent. Our results support
the idea that affect should be considered an important determinant
of adherence.

Introduction
Previous medication adherence studies focus mainly on practical barriers that prevent
patients from being adherent (such as forgetfulness or medication costs) or the deliberate
decisions to be non-adherent (Horne et al., 2013; Lehane & McCarthy, 2007; Wroe, 2002).
In this view, the influence of impulsive processes is largely ignored, even though it has been
shown to be a relevant predictor in many other behavioral domains (Hofmann, Friese, &
Wiers, 2008).
The basis of impulsive processes is the spreading of activation of associations (Strack &
Deutsch, 2004). Upon perception of a stimulus associations are activated which can influ-
ence behavior via the tendency to approach or avoid that stimulus. In previous studies in
the energy domain first associations were found to be correlated with attitudes towards
nuclear power plants and risk assessments of nuclear waste (Keller, Visschers, & Siegrist,
2012; Slovic, Flynn, & Layman, 1991). However, no studies have investigated the associ-
ations that patients have with taking their medication and whether these associations are
related to adherence behavior. Therefore, we assessed patient’s first associations to taking
their medication and their medication adherence in the current study.

CONTACT  Mieke Kleppe  mieke.kleppe@han.nl

© 2017 Informa UK Limited, trading as Taylor & Francis Group
 1218   M. KLEPPE ET AL.

Method
Participants
525 patients (301 male) taking medication for diabetes (61%), cardiovascular diseases (48%) or
hypertension (21%) participated. Participants’ age ranged from 18 to 88 (M = 58.1, SD = 11.6).

Procedure and measures

Medication adherence
Medication adherence was assessed with the ProMAS (Kleppe et al., 2015). The ProMAS is
a Rasch-based questionnaire that consists of 18 items with a dichotomous response format
(e.g. It has happened at least once that I forgot to take (one of) my medicines; I faithfully
follow my doctor’s prescription concerning the moment of taking my medicines). Consistent
with the original study, adherence scores were calculated in logits using Winsteps (relia-
bility = .72; Linacre, 2007; for more information on Rasch analysis see Kleppe et al., 2015).
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Associations
Affective imagery was used to measure medication taking related associations (based on
Keller et al., 2012; Leiserowitz, 2005). To reduce potential biases, participants were asked
write down their first associations (‘If you think about taking your medicines, what is the
first word, image or thought that comes to mind?’). In the second step participants were
asked to indicate how positive or negative they evaluated their own association on a scale
ranging from extremely negative −3 to extremely positive 3 (affective ratings).
Categories were composed to analyze the content of the associations. The initial set of
categories was based on literature (Horne et al., 2013; Krueger, Berger, & Felkey, 2005;
Lehane & McCarthy, 2007). Three raters independently categorized each of the reported
associations. In cases of disagreement, the raters discussed until agreement was reached.
Categories were merged or added when necessary (see Table 1 for final categories).

Avoidance tendencies
Avoidance tendency was assessed using 12 statements (e.g. ‘I’d rather avoid my medicines’
and ‘I feel aversive towards my medicines’). Participants indicated their agreement on a
five-point scale, ranging from not at all to to a very high extent (α = .86).

Attitudes
We measured affective and cognitive components of attitudes towards medication taking
behavior using bipolar adjective scales on a seven-point scale (based on Lawton, Conner, &
McEachan, 2009; Trafimow & Sheeran, 1998). Participants were asked ‘I consider taking my
medication to be...’. Cognitive attitudes included eight items (e.g. important-not important,
valuable-not valuable, good-bad and wise-not wise; α = .92). Affective attitudes included
eight items (e.g. disappointing-not disappointing, annoying-not annoying, tiresome-not
tiresome and nice-not nice; α = .91).

Intention
Participants were asked to indicate whether they were planning to take their medication
exactly as prescribed on a five-point scale ranging from very unlikely to very likely.
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Table 1. The categories (ordered by number of participants) with their descriptions, examples of associations mentioned by participants and the average affective
rating for the statements in this category.
Category N (%) Description Examples of associations Affective ratings
Description 93 (18) Neutral description of taking medication ‘Water’, ‘swallowing’, ‘(with) food’, ‘pills’ Positive (M = 1.09, SD = .19)
Negative affect 79 (15) Included a feelings aspect ‘Bah!’, ‘misery’, ‘Pfffffft!’, ‘again those rotten medicines’, ‘annoying’ Negative (M = −.95, SD = 1.12)
Routine 63 (12) Routine or habit ‘automatic’, ‘I do it without thinking’, ‘daily routine’, ‘regular’ Positive (M = 1.24, SD = 1.00)
Positive effects 58 (11) Positive outcomes of medication ‘Getting better’, ‘health’, ‘eases the pain’, ‘cure’, ‘it is good for me’ Positive (M = 1.41, SD = 1.06).
No association 57 (11) No specific association mentioned ‘none’, ‘I think of nothing’, ‘no idea’, ‘nothing’ Slightly positive (M = 0.31, SD= 1.09).
Necessity 50 (10)   ‘Need’, ‘necessity’, ‘important’ and ‘discipline’ Positive (M = 1.06, SD= 1.24)
Unclear (missing) 33 (6) More information was necessary to be ‘many’, ‘Too late’, ‘adherent’ Slightly positive (M = 0.56, SD= 1.35)
able to categorize answers (e.g. could be
interpreted in different ways).
Forgetting 25 (5)   ‘do not forget’, ‘Sometimes I forget’ Slightly positive (M = 0.28, SD = 1.43)
Negative aspect of illness 24 (5)   ‘illness’, ‘pain’, ‘side-effects’, ‘poison’, ‘patient’ Negative (M = −1.17, SD = .94)
or medication
Obligation 18 (3)   ‘have to’, ‘no choice’, ‘Obligation’ Slightly positive (M = 0.28, SD = 1.64)
Ambivalence 17 (3) An affective statement combined with a ‘Necessary evil’, ‘Sucks that it is necessary’, ‘Unpleasant obliga- Negative (M = −0.82, SD = 0.81)
statement about the necessity tion’
Doubt 8 (2)   ‘is it really necessary?’, ‘do I need that many?’ Neutral (M = 0.13, SD = 1.46)
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Beliefs about medicines

Beliefs about medicines were assessed using the specifics sub-scale of the Beliefs about
Medicines Questionnaire (BMQ; Horne, Weinman, & Hankins, 1999). Participants were
asked to indicate how much they agreed or disagreed with each of the ten statements on a
5-point scale ranging from disagree to agree (necessity beliefs; α = .86; concerns; α = .76).

Results
Affective ratings
More positive affect ratings were correlated to higher adherence (r = .29, p < .001), stronger
necessity beliefs (r = .14, p < .001), less concerns (r = −.36, p < .001), positive cognitive
attitudes (r = .37, p < .001), positive affective attitudes (r = .51, p < .001), less avoidance
tendencies (r = −.42, p < .001) and stronger intentions to take medication as prescribed
(r = .20, p < .001). Fisher’s z-scores indicated that affect ratings correlated stronger with
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concerns than with necessity beliefs (z = 3.78, p < .001), stronger with affective attitudes
than with cognitive attitudes (z = 2.82, p < .01) and stronger with avoidance tendencies
than with intentions (z = 3.96, p < .001).
We performed a mediation analysis (using bootstrapping; Preacher & Hayes, 2004) with
two possible mediators (intentions and avoidance tendencies; see Figure 1). Avoidance
tendency and intentions both partially mediated the relationship between affect ratings and
adherence (B avoidance = 0.10, 95% CI: 0.060–0.15; B intentions = 0.07, 95% CI: 0.039–0.12).

Categories of associations
Adherence scores varied over the different categories (F(11,524) = 3.58, p < .001; see Table 2
for adherence scores per category). Adherence scores were highest for participants whose
associations were categorized as necessity, followed by those categorized as routine, no asso-
ciations or positive effects. Adherence scores were lowest for participants categorized as
negative affect, followed by obligation, doubt, negative aspect of illness or medication, and
ambivalence.
BMQ necessity scores did not vary over the different categories (F(11,524) = 1.13, ns). In
contrast, BMQ concerns did vary over the different categories (F(11,524) = 5.55, p < .001).

Figure 1. The direct and indirect effects of affective ratings on medication adherence.
 PSYCHOLOGY, HEALTH & MEDICINE   1221

Table 2.  Number of participants, mean adherence rates, affective ratings, avoidance tendency, BMQ
concerns and BMQ necessity per category.
Adherence Affective Avoidance BMQ con- BMQ Neces-
Category N (%) (SE) rating (SE) tendency (SE) cerns (SE) sity (SE)
Total 325 (100) 1.17 4.47 1.96 2.80 4.10
Description 93 (17.7) 1.16 (.16) 5.09 (.12) 1.86 (0.06) 2.78 (0.09) 4.20 (0.08)
Negative affect 79 (15) .51 (.18) 3.05 (.13) 2.51 (0.10) 3.27 (0.10) 4.12 (0.09)
Routine 63 (12) 1.42 (.20) 5.24 (.15) 1.81 (0.07) 2.56 (0.12) 4.06 (0.10)
Positive effects 58 (11) 1.32 (.21) 5.41 (.15) 1.76 (0.08) 2.63 (0.12) 4.10 (0.10)
No association 57 (10.9) 1.44 (.21) 4.31 (.15) 1.81 (0.08) 2.54 (0.12) 3.87 (0.11)
Necessity 50 (9.5) 2.07 (.22) 5.06 (.16) 1.64 (0.08) 2.42 (0.13) 4.33 (0.11)
Unclear (missing) 33 (6.3) 1.01 (.27) 4.56 (.20) 1.84 (0.10) 2.67 (0.16) 4.10 (0.14)
Forgetting 25 (4.8) 1.02 (.32) 4.28 (.23) 1.82 (0.10) 2.67 (0.18) 4.05 (0.16)
Negative aspect 24 (4.6) .76 (.32) 2.75 (.23) 2.31 (0.15) 3.34 (0.19) 3.96 (0.17)
of illness or
medication
Obligation 18 (3.4) .57 (.37) 4.28 (.27) 1.99 (0.19) 3.14 (0.22) 4.10 (0.19)
Ambivalence 17 (3.2) .91 (.38) 3.18 (.28) 2.33 (0.17) 3.38 (0.22) 4.00 (0.19)
Doubt 8 (1.5) .70 (.56) 4.13 (.41) 2.47 (0.37) 3.28 (0.32) 3.92 (0.28)
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Participants with associations in the categories necessity and no associations had the lowest
concern scores, while participants reporting ambivalence, negative aspect of illness or medi-
cation and negative affect had the highest concern scores. Avoidance scores also varied over
the different categories (F(11,524) = 9.25, p < .001).

Discussion
The highest mean adherence rates were found for participants reporting necessity associ-
ations. This correspond with findings from previous studies, where necessity beliefs were
found to correlate with medication adherence (Horne et al., 2013). However, our results
indicated that when explicitly asked for necessity beliefs using a questionnaire, most par-
ticipants evaluated their medication as highly necessary. These findings indicate that the
extent to which necessity beliefs are salient are highly relevant.
The second highest mean adherence rates were found for participants whose associations
were categorized as either routine or no association. For both categories, it is likely that
taking medication is a habit that does not require cognitive thought. Beliefs and feelings
might have influenced the formation of habits, but became less relevant over time. These
findings are consistent with previous research, which showed a strong correlation between
adherence and habits (Zogg et al., 2012).
The lowest mean adherence rates were found in participants whose associations were
categorized as negative affect. Indicating that incorporating affect into interventions might
make interventions more effective (a study using affective interventions shows positive
effects; Ogedegbe et al., 2012). Interesting to note is that the content of the associations in
the negative affect category mostly reported affect related to the moment of intake, rather
than affect related to the longer term. However, participants experiencing negative affect
at the moment of intake also reported high concerns. Future research should study these
types of affect further.
A noteworthy finding from this study is that negative associations reported were mostly
of an affective rather than a cognitive nature, whereas positive associations were mostly
of a cognitive nature. This could indicate that the processes through which behavior is
 1222   M. KLEPPE ET AL.

influenced might be different for positive and negative associations (for more information
see Strack & Deutsch, 2004). Cognitive associations with medication are most likely to
influence adherence via intentions, while affective associations are most likely to influence
adherence via avoidance tendencies.
A limitation of the present study is that the associations assessed were only the first asso-
ciations mentioned by participants. An advantage of this method is that these associations
reported are spontaneous, unbiased by guiding questions and represent only the salient and
accessible associations. A disadvantage is that this method does not acquire information
on the prevalence of each association in the population, which should be studied in future
research.
This study is further limited because of its cross-sectional design, which allows for finding
relationships, but cannot infer causality. Additionally, we could not isolate effects of different
disease groups, as most participants suffered from comorbidities.
In conclusion, this study has provided insights into the salient, unbiased, first associ-
ations that patients have with their medication. These associations seem to be related to
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concerns, avoidance tendency and patients’ medication adherence behavior. Thereby, this
study provides insights into the determinants of non-adherence, ultimately guiding the
development of effective interventions.

Disclosure statement
No potential conflict of interest was reported by the authors.

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