The underlying reasons behind non-adherence
Non-adherence to medication costs the US healthcare system billions of dollars each year, while having an often-detrimental impact on patients’ disease management. But do we fully understand the underlying reasons behind suboptimal adherence, and how we can combat them?
A long-established challenge
It’s a billion-dollar issue which has burdened our healthcare system for decades. It can lead to higher inpatient, outpatient and emergency costs, along with physical suffering and even mortality if left unresolved.1,2 But why is non-adherence to medication so prevalent across therapy areas; what are the fundamental reasons behind it? Obstacles to adherence may be tangible and relatively simple to address, relating to factors such as financial issues. However, the more complex and challenging barriers are those that lie in the psychology of a patient. Due to their complicated nature, research has been predominately focused on this category of adherence issues, which are long-recognized yet remain widespread. These psychological barriers are typically segregated into two distinct types: intentional and unintentional. Understanding the disparities between the two are critical to developing tailored solutions to prevent non-adherence in individual patients.1,3
Intentional vs. unintentional
So how are the two categories distinguished? If a patient actively chooses not to use a treatment or follow treatment recommendations, this is classed as intentional or intelligent non-adherence. This involves a rational decision-making process, where the individual considers what they perceive to be the pros and cons of the treatment, and any beliefs they may have. Consider the impact of a patient information leaflet for instance; after reading, an individual may become skeptical about their medication due to listed side effects and other negative factors such as reduced long-term efficacy or drug dependency. In certain conditions, taking medication may also bring about stigmas or remind a patient of their illness. Factors such as these may result in individuals modifying or even discontinuing recommended treatments, due a lack of motivation and positive outlook about their medication.1,3,4
Alternatively, when non-adherence is due to unforeseen, passive behavior, we class it as unintentional or erratic. It may be the result of forgetfulness or incorrect use of the medicine; associated with a patient’s memory and the complexity of a treatment regime, rather than opinions and level of cognition. These individuals may believe they are correctly adhering to medication, but in fact may be forgetting to take their medication on time, or poorly recalling instructions relating to use. Changing work schedules or chaotic lifestyles can also mean patients don’t prioritize their disease management, or struggle to establish the habit of a new medication.3,4
It has been formally recognized that patient-centered care is vital to enhancing 21st century healthcare. By actively engaging individuals in decision-making and viewing them as experts on their own experiences and challenges rather than as a passive bystander, patients and physicians can create adherence strategies for the individual’s situation.1 Several non-adherence interventions have been developed with this model in mind, to address both intentional and unintentional subsets. These have primarily focused on enhancing health literacy; simplifying treatment regimens; increasing motivation through effective communication; and involving multiple members of an individual’s healthcare team to create a tailored, multifaceted strategy to combat non-adherence.1
While these interventions are well-established as effective methods of improving adherence, we are still underutilizing a key tactic that can be used alongside these strategies to fortify them. Technological interventions have been demonstrated to be effective in increasing treatment adherence with varying levels of sophistication, including simple text reminders.3 Despite this, digital health solutions are not routinely used in clinical practice to prevent non-adherence. Discover more about the potential for digital health interventions in our whitepaper, ‘Technology and Healthcare: A call for collaboration’.
- Martin LR et al. Patient Prefer Adherence 2018; 12: 1527–1535.
- New England Healthcare Institute. Thinking Outside the Pillbox. A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease. Available at: https://www.nehi.net/writable/publication_files/file/patient_adherence_onepager_2009.pdf. Accessed: December 2019.
- Hugtenburg JG et al. Patient Prefer Adherence 2013; 7: 675–682.
- WHO. Adherence to Long-Term Therapies – Evidence for Action. Available at: https://apps.who.int/medicinedocs/en/d/Js4883e/8.1.3.html. Accessed: December 2019.
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