Mental-physical multimorbidity treatment adherence challenges in Brazilian primary care: A qualitative study with patients and their healthcare providers

Improved understanding of multimorbidity (MM) treatment adherence in primary health care (PHC) in Brazil is needed to achieve better healthcare and service outcomes. This study explored experiences of healthcare providers (HCP) and primary care patients (PCP) with mental-physical MM treatment adherence. Adults PCP with mental-physical MM and their primary care and community mental health care providers were recruited through maximum variation sampling from nine cities in São Paulo State, Southeast of Brazil. Experiences across quality domains of the Primary Care Assessment Tool-Brazil were explored through semi-structured in-depth interviews with 19 PCP and 62 HCP, conducted between April 2016 and April 2017. Through thematic conent analysis ten meta-themes concerning treatment adherence were developed: 1) variability and accessibility of treatment options available through PHC; 2) importance of coming to terms with a disease for treatment initation; 3) importance of person-centred communication for treatment initiation and maintenance; 4) information sources about received medication; 5) monitoring medication adherence; 6) taking medication unsafely; 7) perceived reasons for medication non-adherence; 8) most challenging health behavior change goals; 9) main motives for initiation or maintenance of treatment; 10) methods deployed to improve treatment adherence. Our analysis has advanced the understanding of complexity inherent to treatment adherence in mental-physical MM and revealed opportunities for improvement and specific solutions to effect adherence in Brazil. Our findings can inform research efforts to transform MM care through optimization.


S1 Appendix Exemplary Interview Topic Guides (English & Portuguese)
A conversational style of interviewing was adopted, to encourage comfortable and fluent dialogue rich in detail, while using a semi-structured interview topic guide as a reference to ensure that all key topics were covered. We have attempted to cover each key topic with each interviewee. Consistent with good qualitative research practice, main questions and prompts [text in square brackets in grey font] varied in each interview, the former dependent on whether the participant already spontaneously covered that topic or not and the latter dependant on the participant's experience and their opening narrative.

Interviews with Physicians
[Topic guide questions were tailored to specific healthcare professional group, according to relevance] • Opening question: Could you describe your role/ involvement in care for people with diabetes, hypertension, heart disease or arthritis/arthrosis in the primary care unit where you work?
• There are people who have two or more of these chronic illnesses at the same time (for example, diabetes, hypertension, heart disease or arthritis). Is your involvement in care for these people any different compared to your involvement in caring for people who have only one of these chronic diseases?
• Some health professionals say that they have observed that some patients do not feel comfortable when they tell them their problems and difficulties. Has  • How do you know if every patient you are seeing who has diabetes, hypertension, heart disease or arthritis is getting help for any of these chronic illnesses at other health care services other than the one where you work? [If so, can you give me more details on how you got to know? If not, can you give me more details on why you can't find out?] • How do you know which medications have been prescribed for each of your patient who has a chronic illness, including those medications that have been prescribed in health services other than the health service here, where you work? [If so, can you give me more details on how you got to know? If not, can you give more details on why you can't find out?] • How do you know if the patients you care for are taking the medications they were prescribed correctly?
• How do you find out which of the patients you care for have diabetes, hypertension, heart disease or arthritis? [In your experience, what are the best diagnostic methods for hypertension, diabetes, heart disease, arthritis to use in Primary Care?] • When you have to decide how you decide which treatment is best for a patient with one or more of these chronic diseases? [For example, how do you decide to advise a patient to take specific medications, or to do some kind of physical activity, or to eat certain types of foods? How is your use of the "Primary Care Notebooks", from the Ministry of Health, to help you plan and decide what is the best treatment for your patients?] • What treatments or ways to help treat are offered for hypertension, diabetes, heart disease, arthritis / arthrosis in your care unit?
• Of the treatments that are offered for these chronic illnesses in this health service, which ones do you think help the patients a lot and which ones do you think do not help that much? [Why do you think that? Do you think there is a combination of treatments that is especially good for helping patients with these chronic illnesses?] • If you had a choice, what treatment -or treatments -would you like to offer to patients with diabetes, hypertension, heart disease or arthritis / arthrosis?
• In you experience, people with hypertension, diabetes, heart disease or arthritis, also have co-exiting, emotional problems such as depression or anxiety? [It is common?] • Do you think that hypertension, diabetes, heart disease or arthritis can cause depression and anxiety? [If so, give more details on how you think chronic illnesses can trigger emotional problems.] • Do you think that depression and anxiety can help cause hypertension, diabetes, heart disease, arthritis or osteoarthritis? [If so, give more details on how you think these emotional problems can help to cause chronic illness.] • What else do you think can help cause depression and anxiety?
• What is your involvement in the care of people who have hypertension / diabetes / heart disease / arthritis or osteoarthritis and also have depression and / or anxiety at the same • How do you know if each patient is taking the medication prescribed to treat anxiety and / or depression correctly?
• How do you know, for each patient you attend, if he received any help, other than medication, to treat emotional problems such as depression and / or anxiety, right here in this health service? [Can you give me more details about how you get to know (or why you don't get to know)?] • How do you know, for each patient you see, if he/she received any help, other than medication, to treat depression and/or anxiety, in another health service? [Can you give me more details about how you get to know (or why you don't get to know)?] • What ways of helping people with depression and/or anxiety are offered at the health service where you work?
• In your experience, which forms of treatment work and which forms of treatment do not work well, to help people improve from depression and/or anxiety?
• If you had a choice, what kind of help would you like to offer to your patients to treat depression and anxiety that you would? [Why, this one?] • In your experience, what ways do your patients prefer to treat depression and/or anxiety?
[For example, do some patients prefer to take medication rather than receive some other type of help to treat depression and/or anxiety? Do some patients prefer to receive help of any kind that does not include taking medication to treat depression and /or anxiety?] • When a patient of yours, needs a referral for treatment of chronic illness, can you or someone in your primary care team talk to them about the specialised services in which they could be seen? [If so, how do you or someone on your team manage to make this conversation? If not, why can't you or someone on your team make this conversation?] • When your patients need referrals to treat emotional problems, can you or someone on your primary care team talk to them about specialised mental health services that they could be seen to? [If so, how do you or someone on your team manage to make this conversation? If not, why can't you or someone on your team make this conversation?] • Can you or another professional in the primary care service where you work help the patient to make an appointment or be admitted to other health services, if necessary? [If so, how can you or someone on your team help the patient with this? If not, why can't you or someone on your team help the patient with this?] • Have you ever noticed that any of your patients experienced difficulties with getting care in other health services to treat hypertension, diabetes, heart disease, arthritis / arthrosis, even after you or another professional in this health service made a referral to these other services? [If so, what difficulties have you noticed? How did you deal with these difficulties?] • Have you ever noticed that any of your patients experienced difficulties with getting care in a mental health service, even after you or another professional at this health service made a referral to these other services? [If so, what difficulties have you noticed? How did you deal with these difficulties?] • When your patients are referred, can you or someone from this primary care service provide them with written information (a report, a reference form) to take to the specialist or specialised service? [If so, how do you or someone on your team do this? If not, why can't you or someone on your team do this?] • After your patient has been consulted or admitted to a specialised service, do you or anyone in this primary care service receive a report, a counter-reference form, from that specialised service? [If so, what is the quality of this counter-reference form? If not, why do you think they are unable to provide the counter-reference form?] • Do you or someone in this primary care service talk to your patient about the results of this consultation or admission to the specialised service after it occurred? [If yes, talk more, give details, about these conversations? If not, why doesn't this conversation with the patient happen?] • Thinking about the aspects of care we discussed, how would you describe your satisfaction with communication with other health professionals, including colleagues from this healthcare service and other health facilities on the treatment of their patients? [What works? What aspects need improvement?] • Do you have any suggestion (s) about how communication with other health professionals who look after your patients could be improved?
• Can you recommend some strategies or ways to integrate treatments for chronic illnesses with treatments for depression and / or anxiety, which work here in your health service?
• Do you have any suggestion (s) on how the integration of these treatments for these two types of problems could be improved here in your health service? [For example, ideas about training health professionals or ideas about how to operate a system or equipment that facilitates communication within your health service and/or with other health services?] • Closing question: In the context of our conversation, is there a topic that is important to you, but you haven't had a chance to speak?

Interviews with Patients
[Diabetes and depression are used for illustration purposes, but specific condition would vary from a patient to another] • Have you ever found it difficult to make an appointment or get treatment for diabetes?
[What difficulties did you have? E.g: cost, distance to a service unit, opening hours, waiting time for a consultation at a specialized clinic or others] • How did you managed to resolve those difficulties?
• Some people think that people with darker skin colour or a complicated financial situation may find it more difficult to access health services for diabetes, and others do not think that. What are you experiences with it?
• Among these service locations in which you were attended for diabetes, to which one you come back more often?
• When you come back in this service is it always the same doctor or nurse who takes care of your diabetes?
• In your opinion, is there a health professional or health service that knows you better as a • How have you dealt with these difficulties?
• Some people think that people with darker skin colour or a complicated financial situation may find it more difficult to get help from health services to treat emotional problems [like depression or anxiety], and other people do not. What are your experiences with it?
• Among healthcare services that you attend for depression, which one you most frequently return to?
• When you return to this healthcare service, are you always attended by the same person?
• • Does the health professional who takes care of your depression give you enough time for you to talk about their concerns and their problems with depression?
• Do healthcare professionals that care for your depression, ask about how you are coping with your diabetes?
• What do you do to not feel worse or feel better when you are down or sad?
• What do you do to not feel worse or feel better when you are nervous or worried?
• How satisfied are you with the treatment of depression that you received?
•  of questions 1a, 1b, 1c and 1d, if the answer is positive, you should also ask questions 2a, 2b, 2c, 2d and 2e, before asking the next question in group 1) • 1a -In any of diabetes consultation, has any health professional told you to see an expert or specialist service for diabetes? [Type of health professional / health service?] • 1b -In any of the diabetes consultations, did any health professional tell you to see a specialist or specialised service for depression? [Type of health professional / health service?] • 1c -In any of the depression consultations, did any health professional tell you to consult with a specialist or specialised service for depression? [Type of health professional / health service?] • 1d -In any of the consultations for depression, did any health professional tell you to consult with a specialist or specialized service for diabetes? [Type of health professional / health service?] • 2a -Did this health professional / health service helped to arrange this appointment with the specialist or specialised service?
• 2b -Did this health professional / health service know that you made these consultations with this specialist or specialised service?
• 2c -This health professional / health service gave you some information (report or form) for you to take to the expert?
• 2d -This health professional/health service asked to you about what happened during the consultation with the specialist or specialised service?
• 2e -Did this health professional/health service seem interested in knowing what you thought about the care given to you by the specialist or specialised service to which he referred you?
• In the context of our conversation, is there any other topic that is important to you, but you have not had a chance to speak about yet?