Take as Directed: Improving Adherence in the Primary Care or Specialist Care Setting

Description

How to improve adherence to medical regimens using behavior principles

Learning objectives

Understand how to improve treatment adherence

Know how to communicate treatment plans with patients to improve adherence to medical treatment plans

Factors influencing adherence

Know factors that influence adherence, including patient knowledge and satisfaction, learning and mental health problems, treatment complexity, and patient health beliefs

Perhaps one of the most frustrating aspects of providing health care to families is that of nonadherence to medical recommendations and prescribed regimens. Society has better medical treatment options now than any time in history, yet adherence to treatment in general remains at a median rate of approximately 50% (Rapoff, 1999). The consequences of poor adherence are significant and numerous. Table 1 summarizes some of the problems associated with not following medical recommendations.

Table 1: Negative consequences of poor adherence
Consequence	Examples
Increased office visits	Patient returns for repeated visits when not taking medication as prescribed leads to minimal or no decrease in symptoms
Decreased responsiveness to medication	Patient with increased resistance to antibiotics due to not finishing course as prescribed
Exacerbation of side effects	Patient not noticing improvement on medication so discontinues without consulting provider, resulting in flu-like side effect symptoms
Exacerbation of acute illness	Upper respiratory infection now manifesting as pneumonia as patient did not follow provider's recommendations
Exacerbation of chronic illness	Severe asthma attack for a patient who does not follow plan of care for inhaler treatment
Increased risk of future health problems	Overweight patient not following exercise and diet plan as recommended, increasing odds for obesity and related problems
Increased risk for future inappropriate medical recommendations	Patient's current dose of medication seems to be less than effective so increases or medication changes are made; ineffectiveness is due to patient not taking the medication as prescribed
Impaired provider-patient relationship	Provider may question patient adherence which in turn may irritate the parent/patient; Or patient may question treatment regimen offered by provider and take as desired, resulting in frustration for provider
Impaired caregiver-child relationship	Parent presents child with ADHD as still impaired, even on stimulant medication, when child has not been taking medication as directed

The problems that may result from nonadherence not only include the personal costs to the patient and provider, but also have a negative impact on an already overwhelmed health care system. For these reasons, difficulties with adherence should be assumed and each patient should be questioned as though the provider understands how difficult it can be to follow medical recommendations. For example, asking an adolescent "What system do you have at home to help you to remember to take your medication?" may lead to a more honest answer than asking, "Have you been taking all of your medication?"

Factors leading to non-adherence

Why is adherence such a problem for the typical patient? Research in the area of adherence suggests that there are many factors that impact a patient's ability to adhere to a regimen (Lemanek, 1990). These factors can suggest areas for the provider to consider when trying to improve adherence in the office setting.

Some are out of the provider's control such as the individual characteristics of the patient, parent, or family environment, health care system factors such as patient insurance, and some aspects of the illness such as the chronicity (e.g., diabetes). As a healthcare provider, however, you can impact many aspects of adherence. Table 2 illustrates some of the numerous aspects of healthcare that can be addressed to improve many adherence problems.

Table 2: Areas of healthcare that may impact adherence
Area Related to Adherence	What Can You Do?
Patient Knowledge	Provide verbal and written information to your patients. Draw out complicated relationships on dry-erase boards or a note pad. Be sure that handouts are at a comprehension level understandable by your clientele (e.g., 6^th grade reading level). Consult your word processing program for readability levels.
	Obtain alternative media such as videos or DVD's that discuss the illness or treatment. Consult with pharmaceutical companies and advocacy organizations such as the American Diabetes Association. Patient education is mainstream now so numerous educational support materials are available.
	Provide a notepad and pen for patients to write down important information.
Patient Satisfaction	Ask patients what questions they have.
	Take time to build rapport with patients.
	Make notes of personal events in chart that you can ask about upon return visits.
	Establish an incentive program using rewards such as movie passes or small trinkets from a "treasure box" for adherence and cooperation.
	Conduct patient satisfaction surveys and address problematic areas.
Treatment complexity	Assess accessibility and follow up (e.g., phone triage system; return phone calls) and make improvements as needed.
	Simplify regimens as much as possible. For example, have patient take medication the same time they perform other aspects of the regimen.
	Ask questions about family's routine and incorporate treatment into established routines.
	Tailor a regimen that will work best for the patient and gradually increase goals until ideal care is reached if possible.
	Provide written diagrams, schedules and handouts at a low readability level (e.g., 6^th grade). Consider developing a checklist for patients to use to monitor adherence.
	Provide a follow-up phone call several days after the regimen is introduced to answer any questions.
	Have support personnel available by phone to answer questions in a timely manner.
	Increase frequency of follow-up appointments until family has mastered the regimen.
Learning Problems	Assess for preferred learning style of parent and child (e.g., hands-on learning, reading, listening). Help family delineate individual roles in regimen if needed. If the child is not capable to manage regimen on her own, regardless of age, recommend more parental involvement.
	Provide written diagrams, schedules and handouts at a low readability level (e.g., 6^th grade).
	Increase frequency of follow up appointments.
Behavioral Problems	Assess for behavioral problems on the part of the child. Provide guidance to parents on how to improve general adherence before focusing on medication adherence if possible.
Behavioral Problems	Provide incentive programs based on cooperation with care. Pharmaceutical companies also offer motivation programs for children who follow their regimens regularly.
Mental Health Problems	If the child has serious behavioral issues, consider a referral to a mental health professional to address as oppositional behavior in general can interfere with specific health regimen behavior.
	Increase frequency of follow up appointments to monitor improvements and follow through with mental health referrals if appropriate.
	If either parent or child displays mental health problems such as depression, consider a referral to a mental health professional. Family stressors can also impact adherence and recommendations for family therapy may also be appropriate.
Cultural/Personal beliefs about healthcare	Provide cultural awareness training for yourself and your staff. Establish office case conference times to discuss difficult cases related to cultural or other issues.
	Offer patients information on other culturally-sensitive, reputable resources, and warnings of unreliable sources. Consult with local cultural centers for resources.
	Ask patients about pressures they anticipate from family or community members (e.g., ostracized for treating depression or ADHD with medication).

Table 2 offered many examples of how the healthcare provider can address specific barriers to adherence for parents and children. Many of the strategies are based on components of successful adherence intervention studies reported in the pediatric literature. Unfortunately, such intervention studies are limited, although an increased focus in this area has been noted (Dunbar-Jacob, Dunning, & Dwyer, 1993; Rapoff, 1999).

Strategies

The most frequently cited and supported strategies for improving adherence fall into the categories of providing illness and regimen information; increasing follow-up care frequency or intensity; providing systematic ways to cue and reinforce health-related behaviors; and combining all of these strategies into a comprehensive intervention (Christophersen & Mortweet, 2001). For example, if you are recommending to the parents of an obese child that the child cut back on fast food, reduce his number of hours in front of the television, and increase exercise, you would be best served to make sure the parent can indeed carry out these difficult recommendations.

Adherence may be improved if you take the time to discuss barriers such as the fact that the child is home alone for many hours after school, or has a grandmother that enjoys feeding him sweets. You might start with having the family focus on one goal at a time, then introduce the other goals leading to more ideal care as the family experiences some success. Schedule more frequent appointments for the family than you would other patients.

You may also establish a checklist for parents to complete to help monitor implementation of an exercise plan, for example, and tell the child you will provide rewards for cooperating with the care. In addition, nursing staff could make phone calls in between appointments to assist with questions. Most complex regimens require complex intervention for adherence. The outcome for the time and effort spent, however, can ultimately be the improved health of the patient, as well as less problems for you and for your office staff.

Child compliance in other areas

Finally, in the area of pediatrics, an often overlooked but important part of the medical adherence equation is that of the general behavioral compliance of the child. It is unrealistic to expect a child who will not follow the directions of her parents on anything else to follow the directions of her parents with respect to medical regimens. Thus, general compliance should be assessed in all patients who are expected to follow any type of complicated regimen.

If the child is in control of most of the decision making in the household, the place to begin may be with behavioral compliance, either through some guidance in your office or through a referral to a qualified mental health professional. You will probably save time and failures by addressing general compliance issues prior to trying to implement a difficult medical treatment protocol.

Often, failures with complicated regimens like Type 1 diabetes could have been predicted by the parent's prior lack of knowledge of strategies for addressing general compliance issues.

This article provides many specific suggestions for how to improve adherence in your patient population. The starting place for improving adherence, however, may be how the concept of adherence is defined and practiced in your setting. In order to help patients to be adherent, the responsibility for adherence must fall on both the patient AND the healthcare provider. Certainly patients must keep the appointments, take the medications as directed, and alter their lifestyles as recommended by the provider.

Healthcare providers have an equal responsibility to provide understandable, individualized patient education, help patients see how aspects of prescribed regimens can fit into their current routines, and to view adherence along a continuum without a succeed or fail mentality. Once parents and patients feel supported in their efforts, they will be more honest about barriers and more willing to consider strategies presented to them regarding regimen follow through. In short, address issues of adherence as a routine part of care instead of waiting for your patients to fail.

Authors

Edward R. Christophersen, Ph.D. FAAP (Hon), is a Board Certified Clinical Psychologist on staff at the Children's Mercy Hospitals & Clinics in Kansas City, Missouri. He is also a Professor of Pediatrics at the University of Missouri at Kansas City School of Medicine. His email address is echrist@cmh.edu

Susan Mortweet VanScoyoc, Ph.D., ABPP, is a Board Certified Behavioral Psychologist on staff at the Children's Mercy Hospitals & Clinics in Kansas City, Missouri. She is also an Assistant Professor of Pediatrics at the University of Missouri at Kansas City School of Medicine. Her email address is svanscoyoc@cmh.edu.

Drs. Christophersen and VanScoyoc (formerly Mortweet) are co-authors of the textbook: Treatments that Work with Children: Empirically Supported Strategies for Managing Childhood Problems (Washington, DC: APA Books, 2001).

Originally published in Development and Behavior News

References

Lemanek, K. (1990). Adherence issues in the medical management of asthma. Journal of Pediatric Psychology, 15, 437-458. [57]
Rapoff, M. A. (1999). Adherence to pediatric medical regimens. New York: Kluwer Academic/Plenum. [58]
Dunbar-Jacob, J., Dunning, E. J., & Dwyer, K. (1993). Compliance research in pediatric and adolescent populations: Two decades of research. In N. A. Krasnegor, L. Epstein, S. B. Johnson, & S. J. Yaffe (Eds.), Developmental aspects of health compliance behavior ( pp. 29-51). Hillsdale, NJ: Erlbaum. [56]
Christophersen ER, Mortweet SL. Treatments that Work with Children: Empirically Supported Strategies for Managing Childhood Problems. Washington, D.C.: APA Books, 2001. [46]