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UNDERSTANDING PATIENT MANAGEMENT: THE NEED FOR MEDICATION ADHERENCE AND PERSISTENCE

BARRIERS TO ADHERENCE

The level of adherence depends on 3 factors namely

1. Patient factors
2. Doctor factors
3. Health System factors

Patient Factors:

Usually the common barriers to adherence are in the patient’s control. The common reasons given by patients for non-adherence14 are listed in Table 1:

Table 1.  Frequency of common reasons cited by patients for non-adherence

Reasons	Percentage
Forgetfulness	30%
Other priorities	16%
Decision to Omit	11%
Lack of Information	9%
Emotional Factors	7%
No Reasons given	2%

It is important to identify patients’ reasons for non-adherence so that we can try and address them and hence improve adherence.

Doctor factors

Doctors can contribute to poor adherence by prescribing complex regimens. Failure to explain the benefits and adverse effects of treatment may well cause poor adherence. Furthermore not paying attention and consideration to patient's life-style also contributes to poor adherence. A poor therapeutic relationship with the patient and not giving consideration to cost of medication will undoubtedly add onto to poor adherence.

Health care system barriers

Health Care systems are often complex and frustrating. These often create barriers to non-adherence. Examples of barriers are listed in Box 2.

Box 2. Health care system barriers to poor adherence

We must take cognizance of these 3 interacting barriers i.e. between the patient, the health care provider and the health care system (Fig 1). Taking these into account will probably have the greatest impact on improving medication adherence.

Fig 1. Interactions between the patient, health care provider and health care system

INTERVENTIONS TO IMPROVE ADHERENCE:

Many intervention techniques have been proposed, designed and tested to try and improve medication adherence. These strategies can be divided broadly into 4 categories namely:

1. Patient education
2. improving communication between patients and doctors improving dosing schedule
3. improving accessibility to care e.g. longer hours when clinics stay open, including evening clinics and decreasing shorter waiting times

Table 2 summaries some of these strategies.

Table 2. Strategies and interventions to improve adherence to medication

Patient Education provide information about illness and its consequences include family members in education enlist ancillary staff to assist in education

Improving Communication between Patients and Doctors elicit patient’s feelings, beliefs and concerns about illness involve patient in decision making explain need for treatment emphasize value of adherence

Improving Dosing Schedule identify poor adherence elicit reasons for poor medication taking presence of adverse events prohibitive costs of medication simplify regimen use once daily dose use of fixed dose combination drugs use more “forgiving” drugs drugs with less adverse events medication with longer half-life medication not dependent on half-life extended release formulations

Improving Accessibility better access to medication shorter waiting time appointments that are more convenient to patients longer opening hours e.g. evening clinics institute an appointment system implement a recall/reminder system