Using Focus Groups to Identify Barriers
Study Objective: To explore barriers to adherence to drug therapy identified by patients with congestive heart failure (CHF).
Setting: University-associated heart failure clinic and a family practice clinic.
Patients: Twenty-six patients with CHF.
Intervention: Four focus group sessions.
Measurements and Main Results: Participants were asked to describe how their lives changed as a result of developing CHF and the challenges they face when taking drugs for the condition. In the second half of each session, participants were asked for their opinions regarding various teaching and memory aids for improving adherence with therapy. They recognized the value of these aids and often created their own when health care professionals did not supply them. Transcripts were reviewed and comments grouped to identify patient-perceived barriers to adherence. The disease placed significant limitations on lifestyle. Furosemide had dramatic effects on daily activities, and some patients altered the dosing schedule to accommodate their plans. Influences on adherence were generalized into five themes: confidence in health care providers; their own knowledge regarding the disease and drugs used to treat it; previous experience with drugs; support from family and friends; and ease of communication with health care professionals.
Conclusion: Focus groups are an effective and efficient method to explore patients' opinions of barriers to drug therapy adherence. Such information can have a direct impact on management of patients with CHF. Information gathered in this study will be used to construct a survey to measure barriers to drug adherence and design interventions to improve adherence.

Congestive heart failure (CHF) is associated with high mortality and morbidity, and is one of the most common reasons for hospitalization. Median survival after the diagnosis is 1.7 years for men and 3.2 years for women. Significant advancements in understanding the biochemical mechanisms of CHF have led to development of several drug therapies. Treatment often requires both long-term preventive therapy with angiotensin-converting enzyme (ACE) inhibitors, ß-blockers, and others, as well as short-term symptomatic treatment with diuretics. Despite irrefutable evidence to support the efficacy of these agents, many eligible patients do not receive them. Furthermore, it is estimated that approximately 50% of patients prescribed life-long therapies will stop taking them after only 1 year.

Ensuring that patients continue taking drugs exactly as prescribed is a major challenge for clinicians. Adherence with therapy, defined as "the extent to which the patient's behavior coincides with the clinical prescription," is influenced by patients' beliefs, attitudes, knowledge, and experience. Patients who are nonadherent are at increased risk for a more severe course of illness, hospitalization, or even death. Nonadherence also has significant financial implications to the health care system as well as to patients and caregivers. Before interventions are designed, greater insight into factors that motivate patients' drug-taking behavior is required.

Poor adherence in patients with CHF can lead to treatment failure and early rehospitalization. Influencing factors, such as social activities, social relationships, and patient confidence with health care professionals and with the diagnosis, are complex. Comprehensive understanding of them may improve the efficacy of interventions. Numerous tools are available to improve compliance with heart failure therapy. They include written and verbal information, group teaching sessions, reminder devices such as drug dispensers and wallet cards, and close contact with a health care provider. Modest improvements in adherence resulted when interventions focused on multidisciplinary programs to improve patient knowledge and simplify dosing regimens.

Focus groups examine areas of interest that are complex due to behavioral and motivational forces. They are well established in marketing research and are accepted in qualitative health services research. A focus group is a form of a group interview that creates a permissive environment allowing participants to interact and share their opinions. As attitudes and perceptions are developed, in part by this interaction, people are able to divulge opinions and beliefs that may not emerge with other forms of questioning. Mail and telephone surveys rely on subjects' ability to understand and articulate exactly how they feel about an issue. In a focus group, participants hear what others say, which may help them to articulate their own viewpoints. This cuing phenomenon may help researchers achieve richer understanding of underlying issues and influences.

To date, most adherence research focused on quantifying compliance with therapy by measuring the rate of drug use and identifying predictors for a high or low rate. Less attention has been given to beliefs and attitudes that influence patients' behavior. We explored issues and barriers to drug use among patients with CHF.