2. Introduction
Patient adherence (or compliance) means correct following of
medical advice by the patient.
Usually the patient takes medication on his own (drug
compliance), but the term adherence may also refer to the use of
surgical appliances, like compression stockings, chronic wound
care, self -directed physiotherapy exercises, or attending
counselling or other therapy courses.
To improve patient adherence, a physician has to build positive
physician-patient relationship.
Medication adherence is categorised into two main concepts, i.e.,
adherence and persistence. Both the concepts are theoretically
similar, but adherence is the intensity of drug use during the
duration of therapy, while persistence is the overall duration of
drug therapy.
WHO defined medication adherence as “ the degree to which
the person’s behaviour corresponds with the agreed
3. Determinants of Medication Adherence
The factors influencing adherence or any health-related behaviour are-
Predisposing Factors: These factors include demographic factors of the
patients, and also their knowledge, attitudes, beliefs and perceptions about
illness and its severity, cause, prevention, and treatment. The Health Belief
Model developed in 1974 predicted adherence or other health -related behaviour
changes in terms of certain belief patterns. The sequence of belief events under
this model, which need to occur if the patient is to be adherent, is as follows:
◦ The patients should believe that their health is in danger.
◦ The patients should identify the potential seriousness of the condition in terms of
symptoms, time lost from work, economic difficulties, etc.
◦ After evaluating the conditions, the patient should believe that benefits from treatment
compensate the costs.
◦ The patient should feel the need to adhere to the medication.
Enabling Factors: These factors are the skills and resources required for
adherence. The term skills refer to the patient’s capability of embracing such
behaviours that will contribute to adherence, e.g., taking an appointment from the
doctor to obtain a prescription. The term resources refer to the availability and
approachability of healthcare facilities such as doctors, pharmacies, clinics, or
hospitals.
Reinforcing Factors: These factors determine whether or not the patient’s
family members, peers, healthcare providers, the local community, and society
are supportive enough to assist in medication adherence. This support may be
positive or negative, and this depends on the attitude or behaviour of the people
4. Monitoring of Patient Medication Adherence
Full medication adherence is required as a drug is effective only when it
is strictly taken on time, in correct dosage and frequency.
Monitoring of medication involves using some observation methods to
check whether or not the patient has taken the medication.
Hence, the effectiveness of the monitoring method plays the major role .
Medication adherence can be measured by direct as well as indirect
methods
In some cases, the providers wish to measure adherence directly by
determining the drug concentration in blood.
However, indirect methods are more commonly used, which include
patient questionnaires, pill counts, refill rates, and clinical response.
Direct Methods
Direct methods of adherence assessment involve direct observation of
the undergoing therapy, measurement of the drug or metabolite level and
of the biological marker in blood. The direct methods are considered to be
more robust than the indirect methods, still they have some limitations.
For example, patients may hide the pills in their mouth and discard them
later, or they may have varied metabolism that will ultimately affect serum
levels. These direct methods are not used practically for routine clinical
5. Monitoring of Patient Medication Adherence
Indirect Methods
Indirect methods of adherence assessment involve patient
questionnaires, self -reports, pill counts, rate of prescription refills,
electronic medication monitors, patient diaries, patient’s clinical response,
and physiological markers.
Morisky’s Medication Adherence Scale (MMAS)was designed to
differentiate between the patients who are poorly adherent and the
patients who are medium -to-high adherent to their antihypertensive
regimen.
MMAS includes questions on multiple reasons for non-adherence;
e.g., a complex regimen can lead to non -compliance, thus the scale
involves a question evaluating whether the patients feel stressed about
their regimen.
Morisky’s medication adherence scale comprises of the following
questions:
Do you sometimes forget to take your high-BP pills?
Over the past 2 weeks, were there any days you did not take your high -BP medication?
Have you ever cut back or stopped taking your medication without telling your doctor because
you felt worse when you took it?
6. Monitoring of Patient Medication Adherence
Pill counts can be easily performed and have been correlated with
electronic medication monitors. They are often used in randomised,
controlled clinical trials to measure medication adherence. However, pill
counts fail to accurately measure the exact timing of medication, and the
data can be even manipulated by the patients ( e.g., pill dumping).
All the indirect methods have their own advantages and disadvantages,
and selecting a specific method for adherence assessment depends on
the clinical scenario and data availability. Electronic pharmacy data are
becoming widely available, and is a frequently used method for
adherence assessment . Obtaining refills and the frequency of acquiring
refills reveal different facets of the adherence behaviour of a patient.
Adherence based on pharmacy refill data and a broad range of patient
outcomes are interrelated.
7. Monitoring of Patient Medication Adherence
Medication possession ratio and the proportion of days covered
methods (defined by the number of doses dispensed in relation to a
dispensing period) are the most commonly used measures of medication
adherence based on pharmacy data. The major difference between these
two measures is that the medication possession ratio accounts for
oversupplies and have a value >1, whereas the maximum proportion of
days covered is 1, indicating full adherence . Using a pharmacy
prescription refill data requires that patients should obtain their
medications in a closed pharmacy system.
Calculating Adherence
There are various calculations for determining adherence based on
pharmacy claims data; however, no single approach has been uniformly
acknowledged.
Medication Possession Ratio (MPR)
8. Monitoring of Patient Medication Adherence
Medication Persistence
Medication persistence is the denominator of the MPR equation and is
used to calculate the duration for which the patient has been taking the
medication, without considering any breaks in the therapy.
Persistence = Last Fill Date – First Fill Date + Last Fill Day’s Supply
Proportion of Days Covered (PDC)
The value of PDC ranges from 0 to 1, of which 1 indicates 100%
adherence . The Pharmacy Quality Alliance (PQA) recommends that
PDC can be used for assessing adherence.
These metrics define adherence as >0.8 or 80% of days covered .
Medications fo r HIV/AIDS and birth control require approximately 100%
adherence for effectiveness.
9. Non-Medication Adherence
Non-compliance is the failure of the patient to obey instructions for
administering the medications as directed, and thus resulting in
lower response of treatment than expected.
The term non-compliance is associated with a patient avoiding
the administration of prescribed drug or following the course of
therapy.
For example, half of the failures in treatment of high blood
pressure occur because of unidentified gaps in taking the
prescribed antihypertensive drugs.
Medication non-adherence is likely to grow as the patients need
more medications to treat the chronic conditions.
10. Causes of Medication Non-Adherence
Non-adherence to medication often results due to multiple factors, and can
be intentional or unintentional. Intentional non-adherence is an active
process in which the patients deliberately deviate from the treatment
regimen.
This may be a sensible decision in which the patients weigh the risks and
benefits of treatment against any adverse effects. Unintentional non -
adherence on the contrary is a passive process in which the patients may
forget taking medicines, thus fail to remain adhered to the treatment
regimen.
WHO has grouped some possible reasons for non-adherence into 5
categories, i.e., healthcare system -, condition-, patient-, therapy-, and
socioeconomic-related factors. Examples of each category are detailed
in table
Reasons for Medication Non-Adherence
Categories of Non-
Adherence
Examples
Healthcare
System
Poor quality of provider-patient relationship, poor communication, lack ofaccess
to healthcare, and lack of continuity of care.
Condition Asymptomatic chronic d isease (lack of physical cues) and mental healthdisorders
(e.g., depression).
Patient Physical impairments ( e.g., vision problems or impaired dexterity), cognitive
impairment, psychological/behavioural, you nger age, and non-white race.
Therapy Complexity of regimen and side effects.
Socioeconomic Low literacy, higher medication costs, and poor social support.
11. Some other causes of medication
non-adherence include:
The patient’s cultural beliefs,
Mistrust of health professional (some patients do not agree with the
healthcare management),
Patients take more drug than prescribed when wanted to speed up the
response to treatment,
Patients cannot read the written materials provided by healthcare
professional and are afraid to take medications,
Patients start feeling that the treatment is unimportant and stop visiting
the health professional,
Patients forget to take medication during the daytime,
Patients have difficulty in opening the bottles containing medications,
Patients have physical limitations and cannot administer the medications
as prescribed (e.g., a patient having severe arthritis cannot take insulin
injection),
Patients are not financially stable enough to afford the medications,
Patients have psychological disorder and fail to understand the need to
take the medication, and
Healthcare professionals fail to educate th e patients about proper
12. Improving Medication Adherence
Many interventions to improve patient adherence have been studied, and
most of these have been patient -oriented and educational interventions.
Oral and written instructions and educational leaflets are the most
frequently studied interventions. Some other regularly studied
interventions are modifying patient behaviour. A few studies have
presented the issue of provider -focused interventions. There is still no
evidence that a single method can improve medication adherence better
than any other method.
The interventional strategies can be provider -targeted or patient -
focused. Provider- targeted interventions include educating healthcare
workers like the physicians, community pharmacists, and nurses.
Patient-targeted interventions include various educational strategies
with oral or written instructions or audio -visual materials. Education is
imparted either to the patients alone or along with their family members
or to groups of patients.
Counselling the patients, home visits, and generating family support to
them also prove to be beneficial in improving medication adherence.
Sustained release and long -acting pharmaceutical formulations reduce
the dosing frequency; while transdermal and depot preparations increase
patient convenience and improve medication adherence.
13. Improving Medication Adherence
The quality of doctor-patient relationship is an important factor that
influences patient medication adherence. According to many adherence
researchers , the patients should involve as equal partners in taking
decisions regarding their healthcare, and doctors should not serve the
role of a sole decision-maker but should act as an expert advisor.
patient education strategies to improve medication adherence:
The most important instructions should be presented first.
Some clearly written instructions that can be easily read should be reinforced.
A medication regimen should be made as per the patient’s daily schedule and
lifestyle.
Patient’s family members should be involved to assist and encourage adherence.
A patient should be made to realise the importance of adherence at follow -up
visits and patient’s effort to comply should also be recognised.
Follow-up visits should be scheduled as per the patient’s previous adherence
record.
Medications which can be given once daily and which causes the least side
effects should be prescribed.
Patients should be informed of the side effects that may occur and the steps to be
taken if they occur, e.g., stop the medicine, contact the doctor, take a simple
remedy , or continue the treatment.
The information should be restricted to four key points.
14. Improving Medication Adherence
Counselling: This involves providing information to the patients about
their illness and its treatment verbally. A true counselling is a two-way
process involving listening as well as talking.
Tailoring or Cuing: This involves matching the medicine regimen with a
patient’s normal daily routine, such as meal times or time to sleep.
Packaging: Using a calendar pack with special packaging is a useful
and inexpensive option, however, it has its own shortcomings.
Simplification of the Regimen: This involves rationalising a patient’s
regimen in such a way that it can be convincingly managed (i.e., a
compromise between the ideal and one that can be achieved). This can
be done without adversely affecting the patient’s treatment results.
15. Pharmacist Role in the Medication Adherence
Pharmacists have a unique role in improving medication adherence
because they can show the medication to the patients and relate any
information to the medication. They provide verbal education and written
individualised instructions to the patients; however, these strategies
alone are not so beneficial.
A few studies have provided evidence of Level II of improved patient
medication adherence due to patient education provided by the
pharmacists.
The patient-pharmacist relationship can be improved by the
strategies:
The pharmacist should be friendly and approachable,
The pharmacist should improve his/her communication skills,
The pharmacist should consider psychological needs of the patient,
The pharmacist should improve patient education,
The pharmacist should encourage the patients to discuss their concerns without
interruption or premature closing,
The pharmacist should elicit patient’s perception of illness and associated feelings
and expectations,
The pharmacist should learn methods of active listing and empathy,
The pharmacist should give clear explanations,
16. Pharmacist Role in the Medication Adherence
The patient-pharmacist relationship can be improved by the
strategies:
The pharmacist should check the patient’s attention to medication adherence,
The pharmacist should make the therapeutic regimen easy,
The pharmacist should be conscious of patient’s wishes,
The pharmacist should involve the patient in treatment decisions,
The pharmacist should improve home support,
The pharmacist should monitor beneficial effects,
The pharmacist should monitor the side effects,
pharmacist should provide a long -term support to the patient and continuity of
care,
The pharmacist should speak the language known by the patient, and
The pharmacist should shorten the pharmacy waiting time.
Apart from patient education, pharmacists also improve medication
adherence by serving the role of an advisor to prescribers on
simplification of drug regimens, by providing medication cards or
medication aids (such as a dosette) to the patients, and by identifying
predisposing, enabling and reinforcing factors contributing towards
medication non- adherence.
The clinical pharmacists in hospitals should measure the factors
