At the beginning of 2010, the all-party pharmacy group met to discuss pharmacists roles in improving medication adherence. Three areas for improvement were highlighted:
- education and training – to increase pharmacists confidence when discussing medicines with patients
- practical tools to help pharmacists monitor and regulate adherence
- universally commissioned initiatives to help adherence.
It was also suggested pharmacists should spend more time talking to patients newly prescribed medicines for long-term conditions. Encouraging adherence means more than just giving information; it involves telling patients a story about their treatment that convinces them there is a need for it.
Adherence is the extent to which patient behaviour matches the recommendations of a healthcare provider. A distinction is often made between intentional and unintentional non-adherence.1,2 With intentional non-adherence,
the patient has decided not to follow the recommendations, whereas with unintentional non-adherence the patient either forgets and/or is not paying attention. Sometimes both elements may be at play.
Adherence factors
Non-adherence to medicines is a problem worldwide. The World Health Organization (WHO) published a comprehensive report on medicines adherence in 2003 that outlined why patients fail to take their medicines and provided some possible solutions.3
Adherence is affected by the interaction of five key dimensions:
• social and economic factors – eg poverty, illiteracy, access to healthcare and medicines, effective social support networks, cultural beliefs about illness and treatment
• healthcare team and system-related factors – eg lack of knowledge, lack of tools, poor communication
• condition-related factors – eg depression has a considerable effect on adherence
• therapy-related factors – eg the dose frequency and the incidence of side effects
• patient-related factors – eg lack of information and skills, difficulty with motivation and self-efficacy, and lack of support for behavioural changes.
As these factors are complex, no single intervention or package of interventions is effective for all patients, conditions and settings. Comprehensive interventions, combining cognitive, behavioural, and emotional components, are thought to be more effective than single-focus interventions. Realistically, a community pharmacist is unlikely to have much control over social and economic or condition-related factors. However, there are some ways in which the pharmacist’s own behaviour, therapy-related and patient-related factors could be tackled to improve adherence.
Communication
According to the WHO, adopting certain communication styles with patients is proven to work. Tactics include:
• making sure your patients are satisfied with the service you generally provide
• talking positively
• providing information
• asking patients specific questions about adherence
• following patients up, building a partnership
• being warm and empathetic and providing emotional support.
Behavioural science also offers useful theories, models and strategies for impacting on patient behaviour. Research focused on changing patients’ attitudes and behaviour has shown the following can work:
• promoting self-care and enhancing patient responsibility
• increasing concern about the consequences of the disease without treatment
• enhancing the perceived value or confidence of treatment
• providing clear patient instructions – start early, ideally when a new treatment is prescribed.
For therapy-related factors, pharmacists should:
• educate the patient about their medications and the conditions for which they are prescribed
• review the patient’s medication history
• continuously monitor the patient’s therapy
• screen for potential adverse effects
• monitor the patient’s ability to take their medications correctly and to adhere to the prescribed therapies.
In 2008, researchers in Denmark published a generic adherence programme to help improve patients’ chronic medication use. Taking the WHO recommendations, they produced an individualised, multi-dimensional adherence counselling programme.4
The process of the intervention was summarised in the following short formula: “Find the patient, get the story, check for errors, find the resources together with the patient, share goals, agree on plan, get it done and follow upâ€.
The model begins by allowing patients to talk about their medication use. The idea is that letting patients tell their story helps pharmacists identify key issues and then helps the patient create a more suitable version of the story, with the right resources and solutions. In this next stage of the model the pharmacist uses ‘coaching’ techniques, in effect asking a series of questions to help the patient realise the answers for themselves. Patients can choose from among the solutions they have come up with during the session, based on what they feel capable of implementing in their own lives. Thus the coaching process is ultimately a means of creating a concordant partnership between the patient and the pharmacist. See table 1, below, for the model’s coaching questions.
According to the researchers, intentionally non-adherent patients have typically made their decisions based on several subjective feelings and experiences (eg misunderstandings, negative feelings, lack of support, lack of confidence in the healthcare system and personnel, lack of confidence in medications, low self-esteem, bad experiences). With unintentional non-adherence, forgetfulness is often the problem and the patient may only need help for the execution of the treatment – hence packaging and reminder technologies may be helpful. Therefore very different approaches are needed to improve adherence depending on the patient’s type of non-adherence.
Helping patients with adherence is not a straightforward task. Although a plethora of studies exists, the inconclusive nature of the evidence means there is no definitive best practice advice. Complex interventions that take account of individual patient situations combined with enhanced delivery/communication skills might work in some cases, where story telling and discovering patient resources could lead to an agreed action plan and further follow-up.