How to Make Patients Want Medication They Have to Do

How to Make Patients Want to Do Medication They Have to Do

Anna Jo(blessedanna.j@gmail.com)
Jiyoung Ryu(jyryu1@gmail.com)

Summary

As solvers of this challenge, we identify that the seeker for this challenge is
interested in several approaches, case studies, previous literatures describing the factors how
people, especially patients, are committed in their routines. The aim of this challenge is to
summarize the current knowledge in the field of overcoming the poor adherence problem in
order to make people “want” to do things they “have” to do. Our approaches begin with how
to overcome poor adherence according to targeted people. Secondly, we apply a typology of
consumer loyalty program to treatment or medication program. Based on the information, we
additionally investigate prior studies which describe several cases of medication adherence
and the medication program. Then, we discuss potential factors for facilitating the higher
level of adherence by employing self-determined motivation and factors affecting medication
adherence. We introduce five sets of factors: social/economic factors, provider-patient/
healthcare system factors, condition-related factors, therapy-related factors/ patient-related
factors. Finally, we discuss strategies to overcome each barrier based on potential factors and
conclude how to achieve in order to achieve higher level of medication adherence.

Table of contents

Summary

The Main Issue
I. A Detailed Description of an Approach, Program, Case Study
1. Several Approaches according to targeted people
2. Loyalty Program Implemented by Consumer-Oriented Companies
3. Case Study: Treatment or Medication Adherence
II. A Discussion of Potential Factors for Facilitating the Higher Level of
Adherence
1. Self-determined motivation
2. Factors affecting medication adherence
III. A Discussion of How the Input from This Particular Case Could be
Implemented for Achieving Higher Level of Sticking to Medication
1. Methods of measuring adherence
2. Achieving higher level of medication adherence

Conclusion

Reference

The Main Issue

I. A Detailed Description of an Approach, Program, Case Study

1. Several approaches according to targeted people
(1) Who don’t consider their personal health a priority
a. One of the factors is lack of understanding the gravity of their illness or the benefit that the
medication will provide.
=>Warning for the amount of damages and physical loss in the case of a unexpected relapse
of the condition of a disease
b. Education concerning the phase and symptom of disease when patients passed their
therapy (Table 2. Case study 1, 2, 3)
c. Offering interview with a terminal patients

(2) Who are not sure they even want to deal with their condition
a. Motivating patients by presenting and sharing success stories of other similar patients
(Table 2. Case study 4)
b. Providing statistical information or experimental results describing the gravity of their
illness.
=> Research says that lack of understanding about seriousness of the disease would result in
lack of motivation.
(Steven Baroletti, PharmD, MBA, etc. Medication Adherence in Cardiovascular Disease,
Circulation. 2010; 121: 1455-1458)

(3) Who are not always convinced in the value of medication
a. Informing patients about medication benefit will help patients to convince about their
medication value.
=> In this case, communication plays critical roles for success of convincing patients.
Doctors may adopt following communication skills for discussing evidence with patients
such as using non-technical language or drawing diagrams with comfortable environments.
(Table 2. Case study 1, 2, 3)

(Reference: Ronald M. Epstein, MD, etc. , Communicating Evidence for Participatory
Decision Making, JAMA. 2004;291(19):2359-2366. doi: 10.1001/jama.291.19.2359)
b. Giving an opportunity to take part in clinical demonstration such as animal tests

(4) Who have lower levels of confidence in themselves and their doctors
a. Encouraging patients by keeping in touch with them and their family using SNS services
b. Providing governmental periodical verification and rating service in homepage of National
Healthcare Service regarding hospitals and doctors before patients see a doctor
=> An in-depth interview studies show that patient-doctor relationship, Outside influence,
Professional expertise are three major areas that should be considered for patients’ beliefs and
preferences regarding how doctors decide to recommend a medication. Following factors
may affect the trust of patients toward medication recommended by doctors and fulfilling
these factors will guard or enhance patient-doctor relationship.
n Patient-doctor relationship: Trust, Familiarity with patient, Shared decision
Making(Addressing equipoise -no clear scientific evidence for 1 treatment choice
over another), Communication honesty
n Outside influence: Distrust toward pharmaceutical detailing(Doctor receiving gifts
from detailers), Cost(Drug equivalency, HMO Regulations, Transparency)
n Professional expertise: Medication knowledge (Effectiveness, Side effects),
Knowledge that the doctor is stayed familiar with current medication information
through lifelong learning strategies such as journal reading and conferring with
colleagues.

2. Loyalty Program implemented by consumer-oriented companies
l Types of consumer loyalty programs and application of treatments or medication
adherence based on the loyalty programs
There are four broad categories of loyalty programs which are ways for retailers to
encourage repeat purchasing of customers (Berman 2006). In Table 1, type I program is an
elementary connector for customer relationship, in that occasional customers receive same
discount deals as a firm’s best customers. According to Berman(2006), however, type I
program familiar with supermarket program do not guarantee sustainable customer loyal
behavior. In a type II program, consumers get quantity discount based on their total purchase
and easily self-manage their purchase. The reward getting a free good such as a free hair cut

is motivating another purchasing. Type III programs are membership programs which offer
reward points based on the past purchase records of consumers. Major providers of type III
programs are airlines, hotels, credit card companies. Because the type III programs facilitate a
member's accumulating points and increase the variety of reward options, they effectively
promote consumer loyalty. In type IV programs, individual members receive specialized
promotions and rewards based on their purchase history beyond discounts. Therefore, the
type IV programs lead consumer commitment to a firm and enable to provide the most
relevant deals.

Characteristics of Application of
Program Type Loyalty Program Treatment or medication
adherence based on the
loyalty programs
Type I: Members receive -Membership open to all -Periodicals which issue
additional discount at customers Treatment discount coupon
register -Each member receives the
same discount regardless of
purchase history
-There is no targeted
communications directed at
members
Type II: Members receive 1 -Membership open to all -When patients begin their
free when they purchase n customers medication, hospitals or
units -Firm does not maintain a clinics induce them to pay
customer database linking for the entire cost of their
purchases to specific medication including 1 free
customers medication.
-Type III: Members receive -Seeks to get members to -Treatments or medications
rebates or points based on spend enough to receive in one hospital or clinics
cumulative purchases qualifying discount include reward programs so
that patients can accumulate
points which are available on

their health check-up
Type IV: Members receive -Members are divided into -Patients receive specialized
targeted offers and segments based on their healthcare information based
mailings purchase history on their past diagnosis and
-Requires a comprehensive diseases.
customer database of
customer demographics and
purchase history
Table 1. A Typology of Loyalty Program (resorting to the table in Berman(2006))

As with customer relationship marketing, healthcare service providers needs to
consider how to attract people maintain high level of treatment adherence once they start it.
In table 1, we summarized plans to promote treatment or medication adherence for patients
based on each type of consumer loyalty program. Even though consumer loyalty programs
suggest successful adherence schemes, treatments or medication require clsoser individual
care such as disease management.

3. Case Study: Treatment or medication adherence
Representative cases for treatment or medication adherence have been individualized
communication and intervention by telephone or in-person. As described in consumer loyalty
programs, a few cases employ financial incentive programs to enhance efficiency of disease
management.

Case1 Title JAMA, October 13, 2004—Vol 292, No. 14
Influence of Patient Literacy on the Effectiveness of a Primary
Care–Based Diabetes Disease Management Program
Methodology 1) Individualized communication, one-to-one educational
sessions including counseling and medication
management, helps manage glucose and cardiovascular
risks by allowing pharmacists to both initiate and titrate
blood pressure and glucose lowering medications,
including telephone reminders and, when needed,

addressing difficulties with transportation,
communication, and insurance.
2) Intervention by telephone or in person every 2 to 4 weeks
(more frequently if indicated). Communication to patients
was individualized using techniques that enhance
comprehension among patients with low literacy,
including predominantly verbal education with concrete,
simplified explanations of critical behaviors and goals;

“teach-back” to assess patient comprehension; and

picture-based materials. Main topics, revisited throughout
the follow-up period, included treatment goals,
identification of hypoglycemic and hyperglycemic
symptoms, prevention of long-term complications, and
self-care.
Results - Among patients with low literacy, intervention patients
were more likely than control patients to achieve goal.
Patients with higher literacy had similar odds of achieving
goal HbA1c levels regardless of intervention status.
Improvements in systolic blood pressure were similar by
literacy status.
Case2 Title AIDS Care. 2003 Feb;15(1):125-35.
A pilot study of the effects of a behavioural intervention on
treatment adherence in HIV-infected patients
Methodology 1) Individualized education about antiretroviral medication
and their side effects; positive reinforcement and
encouragement; individualized counseling weekly;
follow-up calls; and lifestyle assessment and the
identification of adherence barriers
Results - Enhanced adherence rates from a mean percentage of
80.27 at baseline to a mean of 97.5% at the end of follow-
up (six months time point)
Case3 Title BMJ 325 : 925 doi: 10.1136/bmj.325.7370.925 (Published 26

October 2002)
Interventions used in disease management programs for patients
with chronic illness which ones work? Meta-analysis of published
reports
Methodology 1) More than one intervention.
2) Provider education, feedback, and reminder
3) Patient education, reminders, and financial incentives
Results - Studied interventions were associated with improvements
in provider adherence to practice guidelines and disease
control
Table 2. Analysis of disease management in representative studies

In addition, several medical programs have carried out efficiently perceived
medication regimen under healthcare service provider education, feedback, and reminder. We
summarize three cases including interventions used in disease management programs.

Case1 Title JAMA, October 13, 2004—Vol 292, No. 14
Influence of Patient Literacy on the Effectiveness of a Primary
Care–Based Diabetes Disease Management Program
Methodology 3) Individualized communication, one-to-one educational
sessions including counseling and medication
management, helps manage glucose and cardiovascular
risks by allowing pharmacists to both initiate and titrate
blood pressure and glucose lowering medications,
including telephone reminders and, when needed,
addressing difficulties with transportation,
communication, and insurance.
4) Intervention by telephone or in person every 2 to 4 weeks
(more frequently if indicated). Communication to patients
was individualized using techniques that enhance
comprehension among patients with low literacy,
including predominantly verbal education with concrete,

simplified explanations of critical behaviors and goals;

“teach-back” to assess patient comprehension; and

picture-based materials. Main topics, revisited throughout
the follow-up period, included treatment goals,
identification of hypoglycemic and hyperglycemic
symptoms, prevention of long-term complications, and
self-care.
Results - Among patients with low literacy, intervention patients
were more likely than control patients to achieve goal.
Patients with higher literacy had similar odds of achieving
goal HbA1c levels regardless of intervention status.
Improvements in systolic blood pressure were similar by
literacy status.
Case2 Title AIDS Care. 2003 Feb;15(1):125-35.
A pilot study of the effects of a behavioural intervention on
treatment adherence in HIV-infected patients
Methodology 2) Individualized education about antiretroviral medication
and their side effects; positive reinforcement and
encouragement; individualized counseling weekly;
follow-up calls; and lifestyle assessment and the
identification of adherence barriers
Results - Enhanced adherence rates from a mean percentage of
80.27 at baseline to a mean of 97.5% at the end of follow-
up (six months time point)
Case3 Title BMJ 325 : 925 doi: 10.1136/bmj.325.7370.925 (Published 26
October 2002)
Interventions used in disease management programs for patients
with chronic illness which ones work? Meta-analysis of published
reports
Methodology 4) More than one intervention.
5) Provider education, feedback, and reminder
6) Patient education, reminders, and financial incentives

Results - Studied interventions were associated with improvements
in provider adherence to practice guidelines and disease
control
Case4 Title Womens Health (Larchmt). 2004 Jun;13(5):616-24.
Using success stories to share knowledge and lessons learned in
health promotion
Methodology 1) Community Change Chronicles were formed as a model
to develop success stories about WISEWOMAN(the Well-
Integrated Screening and Evaluation for Women Across
the Nation) projects.
Results - Use of the success stories by healthcare providers and
organizations gaining support for successful activities

Table 3. Representative Medical Programs to Improve Treatment or Medication
Adherence (Cutler et al. 2010)

We briefly explain how various medical programs promote adherence. In CCNC,
educated professionals practice coordination of care, and achieved a 5 to 7 % increase in
adherence rates. GHS implements electronic survey system to collect patients' medication
preferences. In GHS, monitoring patients' medication achieved a 5 to 7% reduction in
monthly costs. In the case of GHC, case managers educate patients and help them find more
affordable medication. As a result, GHC reduces more that $476 per patient.

II. A Discussion of Potential Factors for Facilitating the Higher Level of
Adherence

1. Self-determined motivation
determined
We expect that potential factors for higher adherence in treatment or medication are
highly connected with personal motivation. Some wildly-held theories of motivation are
held
underlying the facilitating the higher level of adherence In this proposal, we mainly describe
adherence.
self determination theory which is tested and produce positive outcomes. There are mainly
two reasons to take some actions: firstly, people expect to get reward such as praise, money,
and achievement of goals; secondly, they want to experience positive feelings that attribute to
positive
love, happiness and fulfillment. In order to explain these reasons, we adopt self
lment. self-determination
theory.

Figure 1. The Self-Determination Continuum Showing Types of Motivation with Their
Determination
Regulatory Styles (Ryan and Deci 2000)

Self-determination theory (Ryan and Deci 2000) proposed that intrinsic motivation
involves voluntarily taking part in an activity without external pressure. Engaging in many
behaviors attribute not to intrinsically rewarding but to helping individuals reach their self-
determined motivation. Both intrinsic motivation such as a tendency to find rewarding or fun
and identified motivation such as acting in accordance with one's values are associated with
positive psychological outcomes including enjoyment, attitudes, values, self-perceptions, and
intentions for future involvement. From these perspectives, we enlarge individual motivation
to individual disease management.

2. Factors affecting medication adherence
According to the World Health Organization, adherence is determined by the
interplay of five sets of factors: social/economic factors, provider-patient/healthcare system
factors, condition-related factors, therapy-related factors/ patient-related factors. In order to
investigate the classified factors, 2006 American Society on Aging and American Society of
Consultant pharmacists Foundation summarized a myriad of published studies.

1. SOCIAL AND ECONOMIC DIMENSION 4. THERAPY-RELATED
DIMENSION
Limited English language proficiency
Low health literacy Complexity of medication regimen
Lack of family or social support network (number of daily doses; number of
Unstable living conditions; homelessness concurrent medications)
Burdensome schedule Treatment requires mastery of certain
Limited access to health care facilities techniques (injections, inhalers)
Lack of health care insurance Duration of therapy
Inability or difficulty accessing pharmacy Frequent changes in medication
Medication cost regimen
Cultural and lay beliefs about illness and treatment Lack of immediate benefit of therapy
Elder abuse Medications with social stigma
attached to use
2. HEALTH CARE SYSTEM DIMENSION
Actual or perceived unpleasant side

Provider-patient relationship effects

Provider communication skills (contributing to lack of Treatment interferes with lifestyle or

patient knowledge or understanding of the treatment requires significant behavioral changes

regimen) 5. PATIENT-RELATED
Disparity between the health beliefs of the health care DIMENSION
provider and those of the patient
Physical Factors
Lack of positive reinforcement from the health care
Visual impairment
provider
Hearing impairment
Weak capacity of the system to educate patients and
Cognitive impairment
provide follow-up
Impaired mobility or dexterity
Lack of knowledge on adherence and of effective
Swallowing problems
interventions for improving it
Psychological/Behavioral Factors
Patient information materials written at too high
Knowledge about disease
literacy level
Perceived risk/susceptibility to disease
Restricted formularies; changing medications covered
Understanding reason medication is
on formularies
needed
High drug costs, copayments, or both
Expectations or attitudes toward
Poor access or missed appointments
treatment
Long wait times
Perceived benefit of treatment
Lack of continuity of care
Confidence in ability to follow
3. CONDITION-RELATED DIMENSION treatment regimen
Motivation
Chronic conditions
Fear of possible adverse effects
Lack of symptoms
Fear of dependence
Severity of symptoms
Feeling stigmatized by the disease
Depression
Frustration with health care providers
Psychotic disorders
Psychosocial stress, anxiety, anger
Mental retardation/developmental disability
Alcohol or substance abuse

Figure 2. Factors Reported to Affect Adherence (2006 American Society on Aging and
American Society of Consultant Pharmacists Foundation)

These 5 categories enlighten how healthcare providers and government agencies
design their overcoming strategies to facilitate higher level of adherence. We discuss the
specific barriers and strategies at the next part.

III. A Discussion of How the Input from This Particular Case Could be
Implemented for Achieving Higher Level of Sticking to Medication

In order to make people “want” to do things they “have” to do, appropriate intervention
and education for patients are key strategies. Major predicts of poor adherence to medication
are presence of psychological problems, patient’s lack of belief in benefit of treatment, poor
provider-patient relationship, complexity of treatment, etc. In Chapter II, we categorized five
kinds of factors affecting medication adherence. In this chapter, we firstly introduce methods
of measuring adherence and then summarize how to solve the barriers in each dimension
based on the above five factors.

1. Methods of measuring adherence
Based on Osterberg and Blaschke(2005), there are direct and indirect methods to measure
adherence. Firstly, direct methods consist of directly observed therapy, measurement of the
level of medicine or metabolite in blood and measurement of the biologic marker in blood
which are accurate and objective methods used in clinical trials. However, these methods
sometimes require expensive quantitative assays and collection of bodily fluids. Secondly,
indirect methods include patient self-reports, rates of prescription refills, and electronic
medication monitors. Most of the methods are simple and easy to perform and obtain data. In
contrast, these methods are susceptible to errors due to data easily altered by the patients. In
the case of indirect methods of measuring adherence, facilitating higher medication
adherence is key to assess the patient's clinical response precisely.

2. Achieving higher level of medication adherence (Source: 2006 American Society
on Aging and American Society of Consultant Pharmacists Foundation)
1) Social and Economic Dimension
Social support is positively associated with medication adherence because people who
have social support from family, friends, or caregivers can be assisted with medication
regimen enabling better adherence to treatment.

Barriers Strategies
Burdensome schedule - Tailor medication regimen to daily routine

- Reminders or compliance aids
High cost or lack of availability - Mail order pharmacy
of transport to access pharmacy - Pharmacy delivery service
Medication cost - Switch to generics or lower-cost alternatives
- Refer to local programs or agencies that provide
medication assistance
- Pharmaceutical assistance programs
( www.helppatients.org )
- Enroll in Medicare Part D prescription drug plan
Cultural Belief - Establish a positive, supportive, trusting
relationship with the person
- Seek an understanding of the causes of illness
from the person's cultural point of view
- Elicit information about use of nontraditional
therapies in non-judgmental way
- Determine person's preference regarding group
learning or individual, private instruction
Table 4. Barrier and Strategies for Social and Economic Dimension

2) Healthcare System Dimension
A good relationship between patient and halthcare provider influences on high
medication adherence.
Barriers Strategies
Provider-patient relationship - Establish a positive, supportive, trusting
relationship with the patient
- Involve the patient in the decision-making process
- Assess the patient's understanding of the illness and
treatment
- Clearly communicate the benefits of treatment
- Involve the patient in setting treatment goals
- Assess the patient's readiness to carry out the
treatment plan

- Identify and discuss any barriers or obstacles to
adherence the patient may have and formulate
strategies for overcoming them with the patient
- Tailor medication regimens to the patient's daily
routine
- Reduce complexity of medication regimen
Provider communication - Adopt a friendly rather than a business-like attitude
- Spend some time conversing about nonmedical
topics
- Avoid medical jargon
- Use short words and short sentences
- Give clear instructions on the exact treatment
regimen, preferably in writing
- Repeat instructions
- Make advice as specific and detailed as possible
- Ask the patient to repeat what has to be done
Table 5. Barrier and Strategies for Healthcare System Dimension

3) Condition-Related Dimension
It is important to consider chronic condition and lack of symptoms for patients with
mental disabilities in order to achieve higher medication adherence.

Barriers Strategies
Therapy for asymptomatic - Inform about disease process, importance of
conditions treatment or prevention, and consequences if not
treated
Preventative therapies with no - Preventative therapies with no immediately
immediately discernible benefit discernible benefit
Chronic or long-term therapy - Simplify regimen
- Refer to support group
- Use reminder strategies
- Involve family members

- Cue medication taking to daily tasks or routine
Lack of belief in treatments’ - Discuss efficacy of medications
effectiveness
Fear of side effects - Review most common side effects
- Reinforce that most people do not have to stop
therapy because of side effects
- Reassure person that over time side effects should
be less of a problem
Patient-related - Cognitive therapy
- Education about the illness
- Education about the treatment
- Memory aids (phone reminders, alarms)
- Involvement in therapeutic alliance
Physician-related - Provide information on common side effects and
strategies to address
- Use of "patient-centered" approach
- Address patient's attitudes and beliefs about
medications
Social/Environment-related - Involve and educate family
- Improve access to mental health services (case
management, home visits, convenient clinic hours
and locations)
- More attractive clinic environment
- Improved coordination between service providers
Treatment-related - Minimize complexity of medication regimen
- Titration to optimum dose
- Provide clear instructions on medication use
- Minimize impact of side effects
- Select medication with fewer side effects
Table 6. Barrier and Strategies for Condition-Related Dimension

4) Therapy-Related Dimension

Barriers Strategies
Complexity of medication - Identify and discontinue unnecessary medications
regimen (number of daily doses; - Reduce dose frequency for medications where
number of concurrent possible; use long-acting dosage forms where
medications) possible
- Identify combination medications that can replace
two separate prescriptions
- Identify opportunities to use one drug to treat
more than one medical condition
- Identify medications prescribed to treat the side
effects of other medications
- Introduce reminder strategies tailored to the
individual, such as pill organizers, calendars,
phone reminder systems, etc.
- Provide updated written list of medications
Lack of immediate benefit of - Educate about what to expect from treatment (e.g.,
how medication works, time to onset of effect,
therapy
expected goals of therapy, how to monitor for
effectiveness)
Chronic or long-term therapy - Simplify regimen
- Use reminder strategies
- Cue medication taking to daily tasks or routine
Actual or perceived unpleasant - Educate about what to expect from treatment and
side effects risks vs. benefits (e.g., tolerance might develop to
certain side effects)
- Suggest ways to manage minor side effects
- Identify alternative medications with less side
effect potential
General treatment regimen - Explore preferences and issues with treatment
concerns regimen:
- Does person believe treatment is needed or
effective?

- Does person want to use medicine to treat
condition?
- Does person have concerns about long-term
treatment?
- Involve person in determining goals of therapy
- Address medication-related issues that make
adherence difficult, such as the need to master
specific administration techniques (e.g., injections,
inhalers)
Table 7. Barrier and Strategies for Therapy-Related Dimension

5) Patient-Related Dimension
Poor medication adherence is sometimes attributed to lack of knowledge about the
disease and lack of motivation, and low self-efficacy. A person's perception of the danger
posed by their disease may influence on medication adherence.

Barriers Strategies
Knowledge - Identify "knowledge gaps"
- Provide information where gaps exist
- Confirm understanding; have person repeat the
information
- Demonstrate any special techniques for use of
devices for administering medication
- Ask about any concerns the person has about using
the medicine
- Provide appropriate written information
- Follow up for reinforcement of the information
provided
Motivation - Use motivational interviewing techniques for
people in the precontemplation and contemplation
stages of change
- "Roll" with resistance

- Involve person in problem solving
- Provide information and alternatives
- Express empathy
- Avoid argumentation
- Develop discrepancy between the person's behavior
and important personal goals
Self-Efficacy - Use motivational interviewing techniques to
enhance the person's confidence in their ability to
overcome barriers and succeed in change
- Recognize small positive steps the person is taking
- Use supportive statements
- Help person set reasonable and reachable goals
- Express belief that person can achieve goals
Table 8. Barrier and Strategies for Patient-Related Dimension

Conclusion

The current knowledge and evidence regarding treatment or medication adherence
suggest that healthcare providers should understand the patients' experience and expectations
to build partnerships. The effort to help patients understand their status enables the
individuals to make a reasonable decision to achieve timely treatment or medication.
Building a relationship on trust and timely intervention and education for patients are the best
course of helping people to stick to their routines.

Reference

Steven Baroletti et al., Medication Adherence in Cardiovascular Disease, Circulation.
2010-Vol 121: 1455-1458
Barry Berman, Developing an Effective Customer Loyalty Program, California
Management Review. 2000 Fall Vol 49: 143-148
Russel L. et al., Influence of Patient Literacy on the Effectiveness of a Primary Care–
Based Diabetes Disease Management Program, JAMA. October 13, 2004—Vol 292, No. 14
Molassiotis A. et al., A pilot study of the effects of a behavioural intervention on
treatment adherence in HIV-infected patients, AIDS Care. 2003 Feb;15(1):125-35
Weingarten SR et al., Interventions used in disease management programs for
patients with chronic illness which ones work? Meta-analysis of published reports, BMJ 325 :
925 doi: 10.1136/bmj.325.7370.925 (Published 26 October 2002)
Cutler et al., Perspective Thinking Outside the Pillbox: Medication Adherence as a
Priority Care Reform, The New England Journal of Medicine,2010; 362:1553-155
Power et al., Obesity, cardiovascular fitness, and physically active adolescents’
motivations for activity: A self-determination theory approach, Psychology of Sport and
Exercise Volume 12, Issue 6, November 2011
R.M. Ryan and E.L. Deci, Self-determination theory and the facilitation of intrinsic
motivation, social development, and well-being. American Psychologist, 55 (2000), pp. 68–
78.
Lewis SD et al., Using success stories to share knowledge and lessons learned in
health promotion. Womens Health (Larchmt). 2004 Jun;13(5):616-24.

Web Resources
Customer Loyalty Program That Works http://hbswk.hbs.edu/item/6733.html
Adult MEDUCATION (2006 American Society on Aging and American Society of
Consultant Pharmacists Foundation) http://www.adultmeducation.com/index.html

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