Diploma of Community Services: Immunosuppressant Adherence Report

This report delves into the critical issue of non-adherence to immunosuppressants following renal transplantation. It emphasizes the importance of studying, measuring, and understanding adherence to prevent complications. The study aims to identify factors and barriers contributing to non-adherence, including social, economic, and psychological aspects, and assesses the potential role of transplant coordinators in improving patient outcomes. The report highlights the significance of interventions, such as educational, behavioral, and psychological strategies, and the use of assessment tools like the TAQ and IMAB questionnaires to understand patient knowledge, awareness, and behaviors. It underscores the need for a patient-centered approach, shared decision-making, and the integration of technology to improve patient adherence to immunosuppressant therapy and reduce the risk of graft rejection.

RUNNING HEAD: DIPLOMA OF COMMUNITY SERVICES
DIPLOMA OF COMMUNITY SERVICES
Name of Student
Name of University
Author note

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Title - Non-adherence to Immunosuppressant’s Following Renal
Transplantation: Can the Transplant Coordinator Make Difference?
Abstract
It is very important that the level of adherence to the drug therapy
(immunosuppressant therapy) is studied, measured ad understood by the health care specialist
in a post-transplant scenario so as to prevent any complications further down the future. The
adherence, good, bad, moderate or poor to immunosuppressant therapy in terms of various
kidney transplant cases – performed in a hospital. One of the major objectives of the study is
to understand the various factors and barriers to understanding of the non-adherence to
immunosuppressant therapy that is targeted at diminishing the immunological function of the
body that are build towards rejecting the graft (la rosa, rubulotta and beesley 2017). The
various types of drug therapy that have adverse reactions in the body can lead to graft
rejection which can have even a fatal impact on the life of the patient. Hence, the TAQ that
was done to identify non-adherence it’s the kind of short recall, BAAIS recall will be
monthly, the IMAB will be used to identify the specific barrier and for each barrier will the
proper intervention (Baron et al. 2017). The study finds out important correlation between the
post-transplant social, economic, socioeconomic factors that leads to immunosuppressant non
adherence and the interventions are recommended on a pertinent basis (Eswarappa et al.
2019).
Objectives
Organ transplantation is a very complex method of coping with organ damage or
pathophysiological failure of the organ due to age related factors, infection, metabolic or
genetic dysfunctions. Systematic issues in the body can also lead to various types of
pathologies that can affect the functionality of an organ. Under these circumstances, it

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becomes very important the organ is replaced so as to restore the normal or at least near
normal functionality of the system that the organ is a part of. It is to be considered that while
various types of interventions are important to maintain the complete health status and well-
being of the patient with organ failure and above all, in severe cases, the most apt way of
managing a severe organ failure situation is organ transplantation (Chisholm-Burns et al.
2016). The aim of the study is to understand non-adherence to immunosuppressant’s
following renal transplantation and to understand whether the transplant coordinator can
make the difference. The study focusses on understanding the various aspects of interventions
and sides of the outcomes in the patient, presented mentally, physically and socially
following a transplantation procedure and it is highly important that the immunological
intervention is controlled in a very profound manner so as to balance the level of suppression
and the level of adherence of the patient to the immunosuppression therapy (Dierickx and
Habermann, 2018). It is very important that the level of adherence to the drug therapy
(immunosuppressant therapy) is studied, measured ad understood by the health care specialist
in a post-transplant scenario so as to prevent any complications further down the future. The
adherence, good, bad, moderate or poor to immunosuppressant therapy in terms of various
kidney transplant cases – performed in a hospital (Kirchhof et al. 2018). One of the major
objectives of the study is to understand the various factors and barriers to understanding of
the non-adherence to immunosuppressant therapy that is targeted at diminishing the
immunological function of the body that are build towards rejecting the graft (Garaix et al.
2018). The purpose of the study is to analyze the underpinnings of the factors that help in the
immunosuppressant adherence process that is again important for the outcomes of the renal
transplant process. The shared responsibilities of the health care staffs in the renal transplant
intervention and the health, behavioral and mental outcomes of the patient in post-transplant
scenarios. The renal transplantation which is done in cases of acute kidney failure, although

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serves to be beneficial under many different circumstances (Shin and Chandraker, 2017). But
as a matter of fact, poses a lot of problems like graft rejection and other issues. That is the
reason why it is very important that the immunosuppression therapy is started in order to
prevent any immunological activation against the transplanted graft (Cossart et al. 2019). But
this has a lot of issues again such as non-adherence to drugs and other immunological
problems when the post-transplant subject shows a non- adherence to the immunosuppressant
therapy (Eisenberger et al. 2017). The purpose of the study is to understand the adherence or
the non-adherence process in relation to immunosuppression process following a renal
transplantation and the objective of the study is not only to differentiate between the various
level of assessments and measurement process required at the post transplantation clinic in
order to understand the entire drug adherence process as the non-adherence to the
immunosuppressant therapy that again lead to various types of physical and mental health
issues and finally leading to graft rejection as well (Opelz et al. 2016). Hence, another
important objective of the study is to identify the various factors that act as markers of non-
adherence to immunosuppressant therapy and how it is done and performed in the clinic,
forms the main pivotal aspect of the research study. The sociological, educational and
psychological aspects are the three main and major factors that are applied in form of both
assessments and interventions that make the clinical care must more focused in a patient
centered manner (Cukor et al. 2017). The various types of assessments that are used in the
post transplantation clinic – are important as well as very pertinent in understand the
behavioral, awareness, psychological and knowledge state of an individual who has already
had a renal transplantation and who is undergoing a immunosuppressant therapy, in the
current state. It is important the patient who has a renal transplantation has good adherence or
moderate level safe adherence with drug therapy and this is why, the educational and the
sociological as well as the psychological assessment are important that they are taken

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properly by the health care professionals working at the hospitals and clinics and it is very
critical that the assessment begin right after the transplantation which in this case, is renal
transplantation and the research study here focuses and aims to understand the various
implications of the patients who are on immunosuppressant therapy and whether they have a
good adherence to the provided or delivered immunosuppressant therapy or not. The study
attempts to understand the correlation between knowledge and actual adherence process to
immunosuppressant therapy following a renal transplantation procedure. The various types of
vital aspects of the objectives that being followed and aimed by the study’s researchers are
focused at understanding the efficiency of the assessments such as in the form of various
questionnaires and various responses to the same questionnaires that determines the sense of
well-being attached and associated with correct and appropriate immunosuppression drug
adherence following a renal transplant.
The objectives of the study can be summarized as follows: -
1. To understand Non-adherence to Immunosuppressant’s Following Renal
Transplantation
2. To understand whether the Transplant Coordinator Make Difference?
3. To understand the effect of educational intervention to better the patient centered care
pertaining to non-adherence to immunosuppressant therapy following a renal
transplantation.
4. To understand the effect of behavioral intervention to better the patient centered care
pertaining to non-adherence to immunosuppressant therapy following a renal
transplantation
5. To understand the effect of psychological intervention to better the patient centered
care pertaining to non-adherence to immunosuppressant therapy following a renal
transplantation.

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State-of-art
The interventions which are planned are educational, then behavioral and also the
mental health interventions are given to the subjects on post renal transplant
immunosuppressant therapy to understand and address the issues pertaining with non-
adherence with immunosuppressant therapy. The various types of the interventions that are
used in the most recent times are motivational interviewing, motivational counselling and the
various other types of therapies and intervention techniques targeted at improving the
knowledge and awareness of the subject or the family of the subject, regarding the sequence
and the functionality of immunosuppressant drugs. With the right knowledge and awareness
of the patient along with the shared decision making policies in the hospital that would
improve just not the adherence rates of the patients with drug therapy but also increase the
performance of the immunosuppressant drug therapy in the patients along with the various
types of other benefits including faster post-transplant recovery and decreased chances of
graft rejection (Bräsen et al. 2017). The various assessments such as the questionnaires can
be used to change the course of action of the post renal transplant subjects in pertinence with
the right method and procedure of drug intake, with water and after or before meal but at
different times of the day.

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The various technological parameters and the various types of questionnaires are very
vital that the same are adhered to in a very pertinent manner, by the clinic coordinator and the
health care staffs involved in the care process so that the financial, social and clinical
concerns of the patients are solved in a very imperative manner. Very importantly though, the
motivational interviewing techniques, in the modern decade and era has been reported to be
very effective and impactful in the making the post renal transplant patient understand the
benefits and vitality of each immunosuppressant drug so that the clinical process and the
immunosuppressant or anti-rejection drug adherence process run in a very efficient manner
and it is vital that the shared decision making is facilitated from the start of the transplant
process and through the course of the post-transplant immunosuppressant therapy, the shared
decision making in the drug adherence process to prevent any adverse effects is very
important indeed. In the modern times – the state-of-the-art targets the holistic treatment and
counselling of the patients with respect to right understanding of the drug adherence process
compliance (DeZern et al. 2019). The self-awareness of the patients with respect to the drug
adherence process is educated as well as a part of the interventions that are used to promote
drug compliance and drug adherence in the patients with post renal transplant conditions, in
relation to non-adherence to immunosuppressant’s following renal transplantation – can be
surely impacted by the transplant coordinator (Sharif and Cohney 2016). In the new age,
there are certain evidence based practice guidelines that are to be practiced by the transplant
coordinator in order to form a more meaningful patient centered care process in the post renal
transplant subjects (Nevins, Nickerson and Dew, 2017). The family can be counseled as well
and recreational activities can also be promoted in order to improve drug adherence in the
post-transplant subjects. Recreational activities can improve cognition and behavior of the
patient who have recall and memory issues and this is very important that the drugs are
undertaken in a normal way without any time and memory issues.

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The different types of interventions pertaining to socioeconomic counselling and the
motivational interviewing as well as the delivery of bundled care and other insurances that
supports the care process is helpful as well. It is very vital that the technologies and the
advanced biomedical technologies are blended with the skilled post-transplant care workforce
to support and aid the process of improving the psychosocial conditions of the patients is also
used as the important intervention method to improve drug adherence with
immunosuppressant therapy. It is critical to understand that the side effects of
immunosuppressant therapy is a huge adverse event and this can lead to deterioration of the
patient’s health as well as the fear of the patient regarding the adverse health condition is
increased and this is where the interventions pertaining to motivational encouragement of the
post renal transplant patient and to help with the physical assessment is critical as well. The
most important aspect of the state of the art in
Methodology
Rationale

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A qualitative data collection will be used in order to understand the individual
perspectives in a better manner and three questionnaires will be used to collect and determine
the data. The idea of this methodology is to understand the educational, social and
psychological perspective from an all-encompassing manner and in order to explore the
various types of gaps pertaining to individual cases of drug and non-drug adherence – would
be remarkable and significant while translating the results of the research to a higher
application setting (Kamar et al. 2016). The questionnaire only reflect and address the
knowledge, perception and level of awareness of the post- renal transplant patients who has
participated in the research but it also reflects on the sociological, personality, behavioral,
emotional, cognitive and physical aspects of the non-adherence issues. The counseling of the
patients in relation to the same will be then delivered. Data will be analyzed using SPSS.
Research philosophy
The various important aspect of the finding that the research study here focusses to
find and understand, is based on a positivist research philosophy. Positivist philosophy refers
to the understanding and collection plus analysis of data based on observation and the data is
objectified. So, a statistical analysis is undertaken on most cases. The main aim of this
research is to direct and understand plus explain and elaboration major underpinnings of the
non- adherence to immunosuppressant therapy based on post-transplant condition of the
patient. Although various factors such as educational, sociological, behavioral and
psychological factors are analyzed in relation to the research problem that is Non-adherence
to Immunosuppressant’s Following Renal Transplantation and how can a Transplant
Coordinator in the post-transplant clinic make a substantial difference to the health condition
of the renal transplant subject, contributing to better behavioral management in relation to
immunosuppressant therapy adherence. Hence, the researchers of this study uses a three
questionnaire system to understand and analyses the data pertaining to behavior, cognition,

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understanding, perception, obedience and awareness, knowledge of the subjects in addition to
the correct lifestyle changes of the patient in order to promote drug adherence in a post-renal
transplant scenario, so that there are least or no chances or risks of graft rejection.
Research approach
An exploratory research is undertaken to understand and realize the role of transplant
coordinator in effective management of the non-adherence cases to immunosuppressant
therapy in a post renal transplant case. The idea of this research is to explore more
possibilities and areas where the awareness and self-care of the individuals in context with
drug adherence has to be managed in a pertinent manner and the exploratory research
provides us with the right opportunity to understand and recognize the new perspectives
about the behavioral, psychological and physical aspects of research in a more apt manner.

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1.1 Population
Randomized controlled trials will be used in order to sample the post-transplant patients in
the transplant clinic.
1.2 Sample Design
300 patients with be selected with random selection, within a period or rather a time span of 3
months.
5 minutes extra time will be required by the transplant coordinator per patients to finish the
Adherence Toolkit questionnaires in a pertinent manner.
1.3 Data Collection
Three questionnaires will be used which are Transplant Adherence Questionnaire, BAASIS –
The Basel Assessment of Adherence to Immunosuppressive medication Scale and IMAB-
Identifying Medication Adherence Barriers.
Three Adherence Toolkit questionnaires with the details are listed -
TAQ –Transplant Adherence Questionnaire:
 Adapted the transplant population from the brief antiretroviral
adherence.
 Completed either as an interview or for the recipient to complete alone.
 Consist of 6 questions recall time of 4 days.
IMAB-Identifying Medication Adherence Barriers:
 Completed either as an interview or for the recipient to complete alone.

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 List 28 statement referring to common barriers to medication taking,
with a category response option for each statement.
 Allows identification and prioritization of barriers for each recipient.
 Implement the appropriate intervention for a particular barrier.
BAASIS –The Basel Assessment of Adherence to Immunosuppressive medication Scale:
 Preferably used as an interview tool, but can also be completed by
the recipient.
 Take 5 minutes to complete and consist of 6 questions recall time
of one month.
Transplant Adherence Questionnaire explores the various aspects of medication
adherence by the post renal transplant subject and how behaviorally, he was inclined himself
or herself with the adherence to immunosuppressant process. It is very critical that the post-
transplant patient understands the various aspects of the important behavioral and cognitive
parameters that are associated immunosuppressant therapy drug adherence. The various types
of important parameters are whether the patient is following the right instructions given by
the clinicians on whether to take the medicine with or without food or just with water and all
these forms the very important perspective of the immunosuppressant therapy drug adherence
process under post- renal transplant conditions (Dharnidharka et al. 2016). Not only on a
qualitative aspect but also on a very quantitative aspect, the questionnaire calculates or rather
collects the data around the patient conditions with respect to the number of times he or she
has missed his doses and this is a vital factor in understanding the cognition and behavioral
implication of the post renal transplant patient. Lastly another very aspect is that the
Transplant adherence questionnaire also provides anti-rejection medication adherence
understanding in a detailed manner as well.

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IMAB-Identifying Medication Adherence Barriers questionnaire provides a more
deep exploration and analysis into the cognition of the patient in relation to adherence to
immunosuppressant therapy under post renal transplant conditions and this is where, the
researchers will take an insightful understanding into the various memory and other issues,
procedural learning, knowledge, awareness and other difficulties involved in the Non-
adherence to Immunosuppressant’s Following Renal Transplantation. The questions are
focused on various minute barriers that can distort and disrupt the behavior of adherence
subject pertaining to immunosuppressant drug adherence. It has been found that more than
everything.
We will use the below algorithm to use the questionnaire
If patient is flagged as none – adhere to medication, we will go to the IMAB questioner to
identify the specific barrier and will be counseled with the relative intervention.

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The above mentioned questionnaire will be completed by the renal transplant patients
in a face to face interview, in the post-transplant clinic itself and at every stage of the
questionnaire filling, the supervisor that is the clinic coordinator might choose to direct or
guide the participants through the adherence questionnaire kit. ‘I find it hard to take my anti-
rejection medication because I forget’ 2. ‘I find it hard to get refills on time, so I run out of
my anti-rejection’ 3. ‘I find it hard to take my anti-rejection medication several times a day.’
4. ‘I find it hard to take my anti-rejection medication because I am unsure about how to take
them 5. I find it hard to remove the anti-rejection medication from the packaging’ 6. ‘I find it
hard to take so many anti-rejection medications at the same time 7. I find it hard to take my
anti-rejection medications because they taste bad’ 8. ‘I find it hard to swallow my anti-
rejection medication’ 9. ‘I find it hard to take my anti-rejection medication when others
notice me taking them’ 10. ‘I find it hard to take my anti-rejection medication when I am
busy with other things 11. I find it hard to take my medication on time as I sometimes fall
asleep or oversleep’ 12. ‘I find it hard to take my anti-rejection medication when I feel too
sick’ 13. ‘I find it hard to remember to take my anti-rejection medication with me when I go
out’ 14. ‘I find it hard to remember my anti-rejection medication if nobody reminds me to
take them’ 15. ‘I find it hard to take my anti-rejection medication because I don’t feel any
benefit from them’ 16. ‘I find it hard to take my anti-rejection medication because I cannot
afford them’ 17. ‘I find it hard to understand the instructions on the anti-rejection medication
packages’ 18. ‘I find it hard to take my anti-rejection medication because I experience side-
effects’ 19. ‘I find it hard to remember whether I have already taken my anti-rejection
medication’ 20. ‘I find it hard to take my anti-rejection medication because I don’t
understand why I need them’ 21. ‘I find it hard to take my anti-rejection medication because
the times I need to take them are inconvenient’ 22. ‘I find it hard to remember to take my
anti-rejection medication during holidays or weekends’ 23. ‘I find it hard to remember to take

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my anti-rejection medication when something interrupts my daily routine (e.g. visit, phone
call)’ 24. ‘I find it hard to stick to my daily routine of anti-rejection medication-taking’ 25. ‘I
find it hard to take my anti-rejection medication when I feel sad or depressed’ 26. ‘I find it
hard to take my anti-rejection medication because I do not understand when to take them’ 27.
‘I find it hard to take my anti-rejection medication when I feel good’ 28. ‘I find it hard to go
away from home and plan the day because I have to take my anti-rejection medication’.
BAASIS –The Basel Assessment of Adherence to Immunosuppressive medication
Scale is similar like the Transplant Adherence Questionnaire but the BAASIS is targeted at
chiefly identifying the non-adherence behaviors in a particular basis. The main explorations
provided by The Basel Assessment of Adherence to Immunosuppressive medication is
whether the subject has already altered the medication or stopped taking the medication
without letting know the attending doctor.

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Data analysis
Mean median and mode analysis
BAASIS
Questions Mean Median Mode Std.Dev Non
adherence
BAASIS_1a 1.816053512 2 2 0.38744054
7
55
BAASIS_1aa 1.982142857 2 2 0.89624357
8
BAASIS_1b 1.642857143 2 2 0.47915742
4
20
BAASIS_1b
a
2.040358744 2 2 0.39410892
5
BAASIS_2 1.846666667 2 2 0.36030851 46
BAASIS_2a 2.092920354 2 2 0.51115292
5
BAASIS_3 1.86 2 2 0.34698703
1
42
BAASIS_4 1.92 2 2 0.27129319
9
24
BAASIS_5 2.34 2 2 0.58685603 120

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Table 1: Results from the Responses found through BAASIS
TAS
Questions Mean Media
n
Mode Std.Dev Non
adherence
TAQ_1 2.15 2 2 0.79214897
6
TAQ_2 2.4 2 2 1.06770782
5
TAQ_3 2.3 2 2 1.1
TAQ_4 1.65 2 2 0.47696960
1
105
TAQ_4a 3.6 4 4 1.2 75
TAQ_5 1.613333333 2 2 0.48698619
6
116
TAQ_6 2.7 3 3 1.05356537
5
120
Table 2: Results from the Responses found through TAQ
IMAB
Questions Mean Median Mode Std.Dev Non

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adherence
IMAB_1 2.8 3 3 0.871779789 18
IMAB_2 2.35 2 2 1.061838029 24
IMAB_3 3.15 3 3 1.194780315 48
IMAB_4 3.05 3 2 1.359227722 48
IMAB_5 2.5 2.5 3 0.974679434 12
IMAB_6 2.6 2.5 2 1.2 24
IMAB_7 2.3 2 2 1.144552314 18
IMAB_8 2.75 3 3 1.042832681 24
IMAB_9 3.05 3 3 1.116915395 42
IMAB_10 2.7 3 2 0.953939201 30
IMAB_11 2.05 2 2 0.739932429 0
IMAB_12 3.1 3 4 1.392838828 56
IMAB_13 2.6 2 2 1.15758369 24
IMAB_14 2.25 2 2 0.766485486 6
IMAB_15 2.75 3 1 1.545153714 42
IMAB_16 2.3 2 2 0.781024968 6
IMAB_17 2.65 3 3 0.963068014 18
IMAB_18 2.8 3 2 1.208304597 36

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IMAB_19 2.95 3.5 4 1.359227722 118
IMAB_20 2.2 2 2 0.6 0
IMAB_21 2.35 2 1 1.235920709 18
IMAB_22 2.6 2.5 1 1.392838828 30
IMAB_23 2.25 2 2 0.766485486 6
IMAB_24 2.9 3 1 1.513274595 48
IMAB_25 2.25 2 2 0.766485486 6
IMAB_26 2.85 3 3 1.194780315 36
IMAB_27 2.9 3 3 1.337908816 42
IMAB_28 2.05 2 2 0.668954408 0
Table 3: Results from the Responses found through IMAB
Findings
It can be said from the findings that in Transplant adherence questionnaires – the
questions 4, 4a and 5,6 were found to be the most common causation of immunosuppressant
non adherence (with the numbers of 105, 75, 116, 120). In the BAASIS, the most common
factors that affects the drug non adherence are 1a, 1b, 2 and 3, 4, 5 plus (with the numbers of
55, 20, 42, 42, 24, 120). In the IMAB questionnaire - the barriers which are most common are
identified in questions 3, 4, 9, 12, 15, 19, 27 (with the number 48, 48, 42, 56, 42, 118, 42). It
was found from the analysis that the social, economic and the sociocultural as well as clinical
and psychological parameters related to an individual matters the most in the post
transplantation conditions. The very important implications of the results are that the
according to the transplant adherence questionnaire is vital that the behavioral parameters are

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very memory and other issues, procedural learning, knowledge, awareness and other
difficulties involved in the non-adherence to immunosuppressant’s following renal
transplantation that it is important that the behavior, awareness and the knowledge are
important that they are addressed in a proper manner. According to the questionnaires, the
major problems arise with immunosuppressant drug adherence as because the overall issues
are linked to forgetfulness mostly and the fact that most of the people taking part in the study
are middle aged and the most of the patients who are a part of this study are also more than
middle aged as well. The various types of conditions has been found out that are affecting the
post kidney transplant immunosuppressant adherence in a great manner but it is also true
forgetfulness and not understanding the exact procedure that is required to use and
applied as a procedural memory execution process has caused the major issues related to non-
adherence in the kidney transplant patients who has participated in this study. This is
highly important to be noted that in cases 3 or more drugs are used, the forgetfulness ratio
increases more in a random manner and as the week progresses and the procedural
knowledge if it is still lacking – would lead to the various types of adherence issues. The
major issues was identified in the fact that the memory and recall formed the major
underpinning of all the non-adherence cases and the ratios of the non-adherence depended on
the fact that the medication adherence is related to motivation, through therapeutic and
counseling interventions and it is to be understood that the transplant coordinator play a very
important role in helping the post-transplant patients with immunosuppressant adherence by
teaching them the right way od remembering the medication names and the various ways of
keeping a schedule to take self-assessments and to help the individuals comply with the
immunosuppressant therapy adherence process in the appropriate manner. The various types
of drug therapy that have adverse reactions in the body can lead to graft rejection which can
have even a fatal impact on the life of the patient. Hence, the TAQ that was done to identify

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non-adherence it’s the kind of short recall, BAAIS recall will be monthly, the IMAB will be
used to identify the specific barrier and for each barrier will the proper intervention.
From the IMAB, we have identified various types of barriers that relates to the
various reasons pertaining to the lack of knowledge and awareness plus self-management that
help adhere to the immunosuppressant drugs on a very timely basis and it is important that
the counselor or the transplant coordinator intervenes in the same areas. It is very important
that the self-management methods like journal keeping, keeping memos and fixing notes on
the wall can surely address the major forgetful issues. In order to help the family help one of
their family members who has underwent a renal transplant – the awareness and the
knowledge parameters has to taught in the right manner and that is why, the group counseling
methods and the interpersonal therapy has to be used in proper application that forms the
basis of the major underpinnings associated with the addressing of problems and barriers
identified in the IMAB questionnaire data filling and collection. The various types of barriers
identified in response to the a person’s state of mind or the psychological parameter is very
important and it is of vital importance that the various methods are identified in the resolution
of the drug adherence problems that are mostly attributed to the perception (negative and
positive) of the post renal transplant patient and more than anything, it is very critical that the
behavior and motivation plus the thought content of the post-transplant patient in relation to
the various types of barriers which are identified in IMAB (Klein et al. 2016). The areas
which are marked as most important from the results of the data are – ‘7. I find it hard to take
my anti-rejection medications because they taste bad’ 8. ‘I find it hard to swallow my anti-
rejection medication’ 9. ‘I find it hard to take my anti-rejection medication when others
notice me taking them’ 10. ‘I find it hard to take my anti-rejection medication when I am
busy with other things 11. I find it hard to take my medication on time as I sometimes fall
asleep or oversleep’ 12. ‘I find it hard to take my anti-rejection medication when I feel too

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sick’ 13. ‘I find it hard to remember to take my anti-rejection medication with me when I go
out’ and this is actually very important that the post-transplant clinic coordinator is apt with
all the counseling and the talk therapy processes that goes in the clinic that is the post-
transplant clinic in addition and response to the various barriers identified, it is very critical
that the clinic coordinator uses the right therapeutic and counseling procedures to help the
client learn about their self and cognitive deficits and also learn how they should be or might
be benefiting from the bridging of gaps required in order to improve self-adherence to anti-
rejection therapy under the post renal transplant conditions. There are certain very vital
interventions that take motivational interviewing, then counseling and then the very shared
decision-making between the multidisciplinary conditions that are very much vital for the
formulation of patient-centered care while trying to improving the different types of
medication adherence in relation to post transplantation immunosuppressant therapy. Helping
the subject understand the value of adhering to the drugs both to improve the quality of life
and the perception about the dangers of non-adherence to immunosuppressant therapy. While
IMAB questionnaire is planned and used plus applied to the participants to understand and
the analyze the barriers pertaining to drug adherence and non-drug adherence and it is vital
that the behavioral parameters are identified rightly in response to bring resolution and
motivation with the right interventions. It can said from the findings that the important role of
the IMAB can be considered in fact that it has been used and applied to right effect that
related to financial factors life of the post-transplant patient and it is indeed very important
that the medical expenses of being and becoming an extra burden in the life of the post renal
transplant patient and this is indeed a very difficult barrier indeed. The socio-financial and the
socioeconomic factors are greatly involved in the building of the expenses, attributing to the
high cost medications which in this case is immunosuppressant therapy targeted that
preventing any chances of graft rejection. It is to be understood that the social determinants of

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DIPLOMA OF COMMUNITY SERVICES
health has to be analyzed by the doctors and nurses as well as the other health care
practitioners at first so that a more proper care delivery in a post-transplant scenario has to be
developed. The post-transplant clinic coordinator has a very critical role to play in the
counselling of patient and help the post renal transplant patient comply with the
immunosuppressant therapy medication guidelines. The very insurance and the bundle
services are to planned before the beginning of the treatment so that the patient or the family
of the patient does not faces any sort of problem afterwards while he has to buy the
medications in a very pertinent way and gets the post-transplant assessments done to check
whether the drug adherence is actually present or not and it is important that the motivational
interviewing focuses not only on increasing the clinical condition and recovery of the patient
along with better ways of adherence with the immunosuppressant drugs but the transplant
coordinator also aid in increasing the chances of the medication adherence through a financial
counseling. It is to be considered from the findings that the side effects of the
immunosuppressant drugs such as nausea, loss of appetite, vomiting, hand trembling and the
various other types of cerebral signs that can be elicited from the overdose or decrease in the
drug intake and the same things must be intervened in a pertinent manner with the
motivational interviewing, group therapy and family therapy. As per the findings, the various
types of important interventions pertaining to the recall and forgetfulness of each of the
patients on post- renal transplant drug therapy as well as the lack of understanding of the
patients regarding the various types of drugs and the importance of knowing each of the
functions performed by each immunosuppressant drug is critical and this has to be bought
into attention of the post renal transplant patient, for better compliance rates and better
adherence to the drug rates can be achieved.
Questions Proposed interventions
Social (1-2-9-10-11-13-14-16-19-21-22-23-24-28) Family counseling and Group therapy

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DIPLOMA OF COMMUNITY SERVICES
• Economic questions (2-16) Financial counseling and shared decision making
• psychological questions -1-3-6-7-8-9-10-11-14-19-24-25-28 – motivational interviewing
• Education questions - 2-4-5-8-12-13-15-17-19-20-21-22-26-27 – workshops and seminars
• Clinical question – 18 - doctor check up

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DIPLOMA OF COMMUNITY SERVICES
Conclusion
Hence, it can be concluded saying that there are many issues that can actually disrupt
the process of medication adherence. It is recommended that how the patient should
continuously be reviewing the timing of medication intake and follows the scheduled time in
order to coincide with the preset regular routines. The patient, as recommended should be
setting alarms and the pillbox should be closed vicinity with the alarms. The reminders in
form of alarms are to be set on the watch, or the computer and the mobile phone. It has to be
understood that educating the patient is important and so is the It should be reviewed on a
constant basis that how the medication has to be taken and with the recipient or the dose
adjustment cannot be discussed or the alternative medication if available must be run through
a recall process, as well. The family and the friends are involved as well who might give
support in order to encourage the medication adherence process and the medications are to be
placed in a shelf or somewhere where they are out of the reach of the children and the spare
medications must be kept at work, at home, in the car and in the pockets of clothing. The
shared decision making process is a very pertinent in the situations where the subject is
showing non adherence.

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DIPLOMA OF COMMUNITY SERVICES
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disorders. oncopaedia cemic, buenos aires argentina, pp.p1-29.
Baron, P.W., Infante, S., Peters, R., Tilahun, J., Weissman, J., Delgado, L., Kore, A., Beeson,
W.L. and de Vera, M., 2017. Post-transplant diabetes mellitus after kidney transplant in
hispanics and caucasians treated with tacrolimus-based immunosuppression. Annals of
transplantation, 22, p.309.
Garaix, F., Stern, M., Lamy, F.X., Dubel, L. and Kamar, N., 2018. Tacrolimus Granules for
Oral Suspension as Post-Transplant Immunosuppression in Routine Medical Practice in
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Klein, O.R., Chen, A.R., Gamper, C., Loeb, D., Zambidis, E., Llosa, N., Huo, J., Dezern,
A.E., Steppan, D., Robey, N. and Holuba, M.J., 2016. Alternative-donor hematopoietic stem
cell transplantation with post-transplantation cyclophosphamide for nonmalignant
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Dharnidharka, V.R., Webster, A.C., Martinez, O.M., Preiksaitis, J.K., Leblond, V. and
Choquet, S., 2016. Post-transplant lymphoproliferative disorders. Nature Reviews Disease
Primers, 2, p.15088.
DeZern, A.E., Zahurak, M., Bolanos-Meade, J. and Jones, R.J., 2019. Shortened
Immunosuppression Following Peripheral Blood (PB) Haploidentical (haplo) Transplantation
with Post-Transplant Cyclophosphamide (PTCy) Is Associated with Tolerable Rates of Graft-
Vs-Host Disease (GVHD).

27
DIPLOMA OF COMMUNITY SERVICES
Dierickx, D., and Habermann, T. M. 2018). Post-transplantation lymphoproliferative
disorders in adults. New England Journal of Medicine, 378(6), 549-562.
Opelz, G., Unterrainer, C., Süsal, C. and Döhler, B., 2016. Immunosuppression with
mammalian target of rapamycin inhibitor and incidence of post-transplant cancer in kidney
transplant recipients. Nephrology Dialysis Transplantation, 31(8), pp.1360-1367.
Sharif, A. and Cohney, S., 2016. Post-transplantation diabetes—state of the art. The Lancet
Diabetes & Endocrinology, 4(4), pp.337-349.
Cossart, A.R., Staatz, C.E., Campbell, S.B., Isbel, N.M. and Cottrell, W.N., 2019.
Investigating barriers to immunosuppressant medication adherence in renal transplant
patients. Nephrology, 24(1), pp.102-110.
Cukor, D., Ver Halen, N., Pencille, M., Tedla, F. and Salifu, M., 2017. A pilot randomized
controlled trial to promote immunosuppressant adherence in adult kidney transplant
recipients. Nephron, 135(1), pp.6-14.
DeZern, A.E., Zahurak, M., Bolanos-Meade, J. and Jones, R.J., 2019. Shortened
Immunosuppression Following Peripheral Blood (PB) Haploidentical (haplo) Transplantation
with Post-Transplant Cyclophosphamide (PTCy) Is Associated with Tolerable Rates of Graft-
Vs-Host Disease (GVHD).
Dharnidharka, V.R., Webster, A.C., Martinez, O.M., Preiksaitis, J.K., Leblond, V. and
Choquet, S., 2016. Post-transplant lymphoproliferative disorders. Nature Reviews Disease
Primers, 2, p.15088.
Dierickx, D., and Habermann, T. M. 2018). Post-transplantation lymphoproliferative
disorders in adults. New England Journal of Medicine, 378(6), 549-562.

28
DIPLOMA OF COMMUNITY SERVICES
Eisenberger, U., Guberina, H., Willuweit, K., Bienholz, A., Kribben, A., Gerken, G., Witzke,
O. and Herzer, K., 2017. Successful treatment of chronic hepatitis C virus infection with
sofosbuvir and ledipasvir in renal transplant recipients. Transplantation, 101(5), pp.980-986.
Eswarappa, M., HJ, G.D., John, M.M., Chennabasappa, G.K. and Siddaiah, G.M., 2019.
Tuberculosis in renal transplant recipients: Our decade long experience with an opportunistic
invader. Indian Journal of Tuberculosis.
Garaix, F., Stern, M., Lamy, F.X., Dubel, L. and Kamar, N., 2018. Tacrolimus Granules for
Oral Suspension as Post-Transplant Immunosuppression in Routine Medical Practice in
France: The OPTIMOD Study. Annals of transplantation, 23, p.561.
Kamar, N., Marion, O., Rostaing, L., Cointault, O., Ribes, D., Lavayssière, L., Esposito, L.,
Del Bello, A., Métivier, S., Barange, K. and Izopet, J., 2016. Efficacy and safety of
sofosbuvir‐based antiviral therapy to treat hepatitis C virus infection after kidney
transplantation. American Journal of Transplantation, 16(5), pp.1474-1479.
Kirchhof, J., Petrakova, L., Brinkhoff, A., Benson, S., Schmidt, J., Unteroberdörster, M.,
Wilde, B., Kaptchuk, T.J., Witzke, O. and Schedlowski, M., 2018. Learned
immunosuppressive placebo responses in renal transplant patients. Proceedings of the
National Academy of Sciences, 115(16), pp.4223-4227.
Klein, O.R., Chen, A.R., Gamper, C., Loeb, D., Zambidis, E., Llosa, N., Huo, J., Dezern,
A.E., Steppan, D., Robey, N. and Holuba, M.J., 2016. Alternative-donor hematopoietic stem
cell transplantation with post-transplantation cyclophosphamide for nonmalignant
disorders. Biology of Blood and Marrow Transplantation, 22(5), pp.895-901.
la rosa, c.s., rubulotta, e. and beesley, a.h., 2017. posttransplant lymphoproliferative
disorders. oncopaedia cemic, buenos aires argentina, pp.p1-29.

29
DIPLOMA OF COMMUNITY SERVICES
Muduma, G., Shupo, F. C., Dam, S., Hawken, N. A., Aballéa, S., Odeyemi, I., and Toumi, M.
2016. Patient survey to identify reasons for non-adherence and elicitation of quality of life
concepts associated with immunosuppressant therapy in kidney transplant recipients. Patient
preference and adherence, 10, 27.
Nevins, T. E., Nickerson, P. W., and Dew, M. A. 2017. Understanding medication
nonadherence after kidney transplant. Journal of the American Society of Nephrology, 28(8),
2290-2301.
Opelz, G., Unterrainer, C., Süsal, C. and Döhler, B., 2016. Immunosuppression with
mammalian target of rapamycin inhibitor and incidence of post-transplant cancer in kidney
transplant recipients. Nephrology Dialysis Transplantation, 31(8), pp.1360-1367.
Sharif, A. and Cohney, S., 2016. Post-transplantation diabetes—state of the art. The Lancet
Diabetes & Endocrinology, 4(4), pp.337-349.
Shin, H. S., and Chandraker, A. 2017. Causes and management of postrenal transplant
diarrhea: an underappreciated cause of transplant-associated morbidity. Current opinion in
nephrology and hypertension, 26(6), 484-493.

30
DIPLOMA OF COMMUNITY SERVICES
References
Baron, P.W., Infante, S., Peters, R., Tilahun, J., Weissman, J., Delgado, L., Kore, A., Beeson,
W.L. and de Vera, M., 2017. Post-transplant diabetes mellitus after kidney transplant in
hispanics and caucasians treated with tacrolimus-based immunosuppression. Annals of
transplantation, 22, p.309.
Bräsen, J.H., Khalifa, A., Schmitz, J., Dai, W., Einecke, G., Schwarz, A., Hallensleben, M.,
Schmidt, B.M., Kreipe, H.H., Haller, H. and von Vietinghoff, S., 2017. Macrophage density
in early surveillance biopsies predicts future renal transplant function. Kidney
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Chisholm-Burns, M.A., Spivey, C.A., Tolley, E.A. and Kaplan, E.K., 2016. Medication
therapy management and adherence among US renal transplant recipients. Patient preference
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Cossart, A.R., Staatz, C.E., Campbell, S.B., Isbel, N.M. and Cottrell, W.N., 2019.
Investigating barriers to immunosuppressant medication adherence in renal transplant
patients. Nephrology, 24(1), pp.102-110.
Cukor, D., Ver Halen, N., Pencille, M., Tedla, F. and Salifu, M., 2017. A pilot randomized
controlled trial to promote immunosuppressant adherence in adult kidney transplant
recipients. Nephron, 135(1), pp.6-14.
DeZern, A.E., Zahurak, M., Bolanos-Meade, J. and Jones, R.J., 2019. Shortened
Immunosuppression Following Peripheral Blood (PB) Haploidentical (haplo) Transplantation
with Post-Transplant Cyclophosphamide (PTCy) Is Associated with Tolerable Rates of Graft-
Vs-Host Disease (GVHD).

31
DIPLOMA OF COMMUNITY SERVICES
Dharnidharka, V.R., Webster, A.C., Martinez, O.M., Preiksaitis, J.K., Leblond, V. and
Choquet, S., 2016. Post-transplant lymphoproliferative disorders. Nature Reviews Disease
Primers, 2, p.15088.
Dierickx, D., and Habermann, T. M. 2018). Post-transplantation lymphoproliferative
disorders in adults. New England Journal of Medicine, 378(6), 549-562.
Eisenberger, U., Guberina, H., Willuweit, K., Bienholz, A., Kribben, A., Gerken, G., Witzke,
O. and Herzer, K., 2017. Successful treatment of chronic hepatitis C virus infection with
sofosbuvir and ledipasvir in renal transplant recipients. Transplantation, 101(5), pp.980-986.
Eswarappa, M., HJ, G.D., John, M.M., Chennabasappa, G.K. and Siddaiah, G.M., 2019.
Tuberculosis in renal transplant recipients: Our decade long experience with an opportunistic
invader. Indian Journal of Tuberculosis.
Garaix, F., Stern, M., Lamy, F.X., Dubel, L. and Kamar, N., 2018. Tacrolimus Granules for
Oral Suspension as Post-Transplant Immunosuppression in Routine Medical Practice in
France: The OPTIMOD Study. Annals of transplantation, 23, p.561.
Kamar, N., Marion, O., Rostaing, L., Cointault, O., Ribes, D., Lavayssière, L., Esposito, L.,
Del Bello, A., Métivier, S., Barange, K. and Izopet, J., 2016. Efficacy and safety of
sofosbuvir‐based antiviral therapy to treat hepatitis C virus infection after kidney
transplantation. American Journal of Transplantation, 16(5), pp.1474-1479.
Kirchhof, J., Petrakova, L., Brinkhoff, A., Benson, S., Schmidt, J., Unteroberdörster, M.,
Wilde, B., Kaptchuk, T.J., Witzke, O. and Schedlowski, M., 2018. Learned
immunosuppressive placebo responses in renal transplant patients. Proceedings of the
National Academy of Sciences, 115(16), pp.4223-4227.

32
DIPLOMA OF COMMUNITY SERVICES
Klein, O.R., Chen, A.R., Gamper, C., Loeb, D., Zambidis, E., Llosa, N., Huo, J., Dezern,
A.E., Steppan, D., Robey, N. and Holuba, M.J., 2016. Alternative-donor hematopoietic stem
cell transplantation with post-transplantation cyclophosphamide for nonmalignant
disorders. Biology of Blood and Marrow Transplantation, 22(5), pp.895-901.
la rosa, c.s., rubulotta, e. and beesley, a.h., 2017. posttransplant lymphoproliferative
disorders. oncopaedia cemic, buenos aires argentina, pp.p1-29.
Muduma, G., Shupo, F. C., Dam, S., Hawken, N. A., Aballéa, S., Odeyemi, I., and Toumi, M.
2016. Patient survey to identify reasons for non-adherence and elicitation of quality of life
concepts associated with immunosuppressant therapy in kidney transplant recipients. Patient
preference and adherence, 10, 27.
Nevins, T. E., Nickerson, P. W., and Dew, M. A. 2017. Understanding medication
nonadherence after kidney transplant. Journal of the American Society of Nephrology, 28(8),
2290-2301.
Opelz, G., Unterrainer, C., Süsal, C. and Döhler, B., 2016. Immunosuppression with
mammalian target of rapamycin inhibitor and incidence of post-transplant cancer in kidney
transplant recipients. Nephrology Dialysis Transplantation, 31(8), pp.1360-1367.
Sharif, A. and Cohney, S., 2016. Post-transplantation diabetes—state of the art. The Lancet
Diabetes & Endocrinology, 4(4), pp.337-349.
Shin, H. S., and Chandraker, A. 2017. Causes and management of postrenal transplant
diarrhea: an underappreciated cause of transplant-associated morbidity. Current opinion in
nephrology and hypertension, 26(6), 484-493.

33
DIPLOMA OF COMMUNITY SERVICES