Strategies to Enhance Patient Adherence: Making it Simple

Ashish Atreja, MD, MPH; Naresh Bellam, MD, MPH; Susan R. Levy, PhD


Abstract and Introduction


The problem of poor patient adherence has been extensively researched, but the rates of nonadherence have not changed much in the past 3 decades. Healthcare providers play a unique and important role in assisting patients' healthy behavior changes. We conducted a narrative review of the current literature to help providers become more familiar with proven interventions that can enhance patient adherence. We then grouped the interventions into categories that can be remembered by the mnemonic "SIMPLE":

  1. Simplifying regimen characteristics;

  2. Imparting knowledge;

  3. Modifying patient beliefs;

  4. Patient communication;

  5. Leaving the bias; and

  6. Evaluating adherence.

Chronic lifestyle behavior change often requires a combination of all the aforementioned strategies. We suggest a conceptual framework, which calls for a multidisciplinary approach with the above strategies in the context of a healthcare team and system-related factors. We hope that this framework would not only help design scientifically proven interventions, but also reduce the time and cost involved with implementing these strategies in a healthcare setting.


The problem of poor adherence to medical treatment is a well-recognized problem in the literature.[1,2,3,4] Studies have shown that in the United States alone, nonadherence to medications causes 125,000 deaths annually and accounts for 10% to 25% of hospital and nursing home admissions.[5] This makes nonadherence to medications one of the largest and most expensive disease categories. Moreover, patient nonadherence is not limited to medications alone. It can also take many other forms; these include the failure to keep appointments, to follow recommended dietary or other lifestyle changes, and to follow other aspects of treatment or recommended preventive health practices. Hence, the actual implications of nonadherence go far beyond the financial aspect of medication nonadherence, as estimated above.

Over the last few years, various constructs of adherence have been conceptualized, and extensive research on the efficacy of adherence-enhancing strategies has been performed. One significant development has been the inclusion of the patient in the determination and success of therapy, with the term "adherence" seeming to indicate this action more accurately than "compliance."[6] However, the rates of nonadherence have not changed much over the past 3 decades. Recent reviews have shown that as many as 40% of patients still do not adhere to their treatment regimens.[7,8]

One possible reason could be the lack of consensus guidelines on this issue. Many of the studies and reviews done have been narrowly focused on one disease condition or one kind of adherence-enhancing strategy. Although this may be useful in a research setting, this fragmented approach may not be practical for healthcare providers dealing with a diverse patient population.[9] In addition, most of the literature on patient adherence has been published in social science journals rather than in the medical literature. This study provides a current review of critical adherence-enhancing interventions across a broad spectrum of patients and diseases and suggests an integrated framework to facilitate their implementation in clinical settings.