Strategies to Enhance Patient Adherence: Making it Simple

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



The individual studies were too clinically heterogeneous and methodologically variable to justify a quantitative meta-analysis. Hence, we chose to do a qualitative synthesis and group the studies into 6 broad categories on the basis of the type of intervention used to address nonadherence (see Table 1 ). This broader focus emphasizes certain common strategies that need to be addressed with respect to all patient-related conditions regardless of their causes.[10] The categories that are described below can be remembered by the mnemonic "SIMPLE."

Simplifying Regimen Characteristics

We have known for some time that the complexity of a treatment regimen can affect adherence. Many of the strategies used to simplify a regimen have already become well-standardized practices. For example, adherence improves remarkably when a patient is prescribed a pill that can be taken once a day.[11] This can be done with a longer acting drug (wherever possible) or with a pill that has more than 1 drug. When a drug regimen cannot be reduced in frequency, it should be matched to the patient's activities of daily living. For example, patients are more likely to remember to take a pill before a meal or before going to sleep. Or, the regimen can be broken down into less complex stages that can be introduced sequentially. However, it is important to note that patients often misinterpret common instructions. Eraker and colleagues,[12] for example, found that only 36% of patients correctly interpreted the meaning of "every 6 hours." Thus, it is important for physicians to use simple, everyday language and have the patient repeat the instructions to ensure proper understanding. Elderly patients are a particular concern because of their common deficits in physical dexterity, cognitive skills and memory, and the number of medications that they are typically prescribed. A variety of adherence aids are available to help patients organize their medications (eg, medication boxes) and remember dose times (alarms). Microelectronic devices can provide feedback that shows patients whether they have been taking their medications as prescribed.[13] Patients can also use devices designed to improve physical dexterity when applying topical preparations, administering insulin injections, operating pressurized inhalers, and administering eye drops. Such devices can help them place drops into their eyes or obviate the need to squeeze an eye drop container.[14]

Imparting Appropriate Knowledge

Research has consistently demonstrated that patients' understanding of their conditions and treatments is positively related to adherence,[15] and that adherence, satisfaction, recall, and understanding are all related to the amount and type of information given.[16]

Many studies have shown that patients do not always understand prescription instructions and often forget considerable portions of what healthcare practitioners tell them.[17,18] Studies have shown that patients who understand the purpose of the prescription are twice more likely to fill it than those who do not understand the purpose.[19]

According to Katz,[20] physicians can provide effective patient education by (1) limiting instructions to 3 or 4 major points during each discussion; (2) using simple, everyday language, especially when explaining diagnosis and giving instructions; (3) supplementing oral teaching with written materials; (4) involving the patient's family members and friends; and (5) reinforcing the concepts discussed.[20] This is especially true for millions of citizens with low literacy skills.

Modifying Beliefs and Human Behavior

For interventions that are complex and require lifestyle modifications, it is worthwhile to address patients' beliefs, intentions, and self-efficacy (perceived ability to perform action). This is because knowledge alone is not sufficient to enhance adherence in recommendations involving complex behavior change.[21,22,23]

Clinicians can optimize behavior change by ensuring that the patients (1) perceive themselves to be at risk due to lack of adoption of healthy behavior (perceived susceptibility), (2) perceive their medical conditions to be serious (perceived severity), (3) believe in the positive effects of the suggested treatment (perceived benefits), (4) have channels to address their fears and concerns (perceived barriers), and (5) perceive themselves as having the requisite skills to perform the healthy behavior (self-efficacy).

Thus, by knowing which of these beliefs is below a level presumed necessary for good adherence, the provider may tailor interventions to suit the unique needs of each patient.[24]

Patient Communication

Patient communication encompasses interventions ranging from physician-patient communication, sending mail or telephonic reminders, to involving patients' families in the dialogue. Of these, the most problematic is physician-patient communication. At least 50% of patients leave their doctors' offices not knowing what they have been told. Studies have shown that (1) 50% of psychosocial and psychiatric problems are missed by physicians due to lack of proper communication[25]; (2) physicians interrupt patients on an average of 18 seconds into the patients' descriptions of the presenting problems[26]; (3) 54% of patients' problems and 45% of patient concerns are neither elicited by the physician nor disclosed by the patient[27]; and (4) 71% of patients stated poor relationships as a reason for their malpractice claims.[28]

Rosenberg and associates[29] devised the following suggestions after conducting a comprehensive review of the existing physician-patient communication literature in books and articles:

Ask a patient about his feelings and concerns (in addition to physical aspects of the problem) and his view about psychological factors on the adherence, so as to arrive at a common understanding to the nature of the problem. Then provide them with information about all areas that [that] individual finds pertinent, and encourage them to share in decision making when a plan for management is formulated.

Most importantly, successful collaboration requires tailoring strategies to individual patients rather than basing communication on general assumptions.[30]

On the same note, communication with the patient's family and the patient's own perception of social support are significantly and positively related to adherence.[31,32,33] The family's role becomes all the more important if a patient is suffering from a chronic disabling condition requiring continued support and understanding.

Leaving the Bias

Much of the early literature in adherence research focused on demographic factors and personality traits that supposedly caused or led to poor adherence. In a review of 185 studies, Haynes[34] found no clear relationship between adherence and race, sex, educational experience, intelligence, marital status, occupational status, income, and ethnic or cultural background. Although some studies have found a correlation of adherence with sex and education,[35] it is believed that this effect is small and may be overcome by tailoring the education to the patient's level of understanding. Moreover, the fact that an individual's level of adherence may vary over time and between different aspects of treatment proves that demographic factors play a minor role in adherence behavior, if at all.[36,37]

Evaluating Adherence

Of note, doctors uniformly underestimate the problem of nonadherence in their patients.[38,39] If a healthcare professional is unable to detect nonadherence, it is impossible for him or her to correct the problem. Hence, it becomes imperative to measure and evaluate patient adherence reliably. This can be done by self-reports, pill counting, and in some cases measuring serum or urine drug levels. Of these, self-report is the most practical and widely used tool. In general, patients can be very accurate in reporting whether they are adhering to their treatment regimens if they are asked simply and directly.[40] Moreover, regular assessment of patient adherence by itself can lead to increased patient adherence.[29]

A simple, 4-item questionnaire designed by Morisky and colleagues[41] was effective in assessing and predicting adherence in 290 hypertensive patients who had been receiving care for their high blood pressure for 6 years.

The questions asked were:

  • Do you ever forget to take your medications?

  • Are you careless at times about taking medications?

  • When you feel better, do you sometimes stop taking medications?

  • Sometimes, when you feel worse, do you stop taking your medicine?

Each yes answer was scored with a 0 and each no answer was scored with a 1. The reliability of the scale was found to be .61 with a sensitivity of .81 and specificity of .44.