Over the last 25 years, researchers have documented the broad impact of behavioral interventions on a range of psychological and physical health outcomes. Despite the promise of evidence-based treatments, a common challenge for practitioners is ensuring treatment adherence to maximize benefits. This is especially challenging for most chronic conditions. Integrating research and recommendations from medication treatment adherence studies can provide avenues for treatment refinement to help ensure patient follow-through with prescribed intervention regimens that involve self management (pharmacological and behavioral).
Treatment adherence goes by many names, including compliance and patient persistence. Lack of adherence can be described as patient resistance. According to the World Health Organization [PDF]:
Adherence is the extent to which a person’s behavior – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.
Although it seems straightforward, adherence is complex; evidence-based treatments only work if patients follow through on guidance. Poor treatment adherence limits the effects of even the most effective treatments. Poor treatment adherence is one of the biggest challenges in public health.
Malleable Factors related to Non-Adherence
Poor treatment adherence is rather common for many health conditions and in many cases related to worsening of the condition and increases in health-related cost. Low adherence is related to individual factors, intervention specific factors and social determinants of health (cost of intervention). Below are common challenges implementing and following through with recommended treatment components with a focus on malleable factors. Each of these points to barriers and beliefs associated with adherence that providers can use to craft communication about adherence with patients.
- Individual
- Patient motivation
- Patient anxiety or depression
- Forgetfulness
- Self-management habits
- Limited knowledge about condition and self management
- Perception of improvement where treatment is no longer needed
- Treatment Specific
- Side effects of medications or intervention
- Psychological triggers
- Inconsistency with beliefs, values, or culture
- Stigma
- Incorporating into daily schedule is not feasible
Treatment Adherence Recommendations: What does the Research Say?
Actionable research-based recommendations are available to help practitioners. Most of these are for medication adherence but can be adapted and included in behavioral health interventions. Careful integration into evidence-based practices can go a long way in improving patient outcomes. Solutions are available to help with individual and treatment specific factors including mobile reminder apps. Insightful and actionable research is available on treatment adherence for patients with irritable bowel disease, problems with addiction and obesity which illustrate key methods in improving patient adherence.
Clinically proven measures that increase adherence include deliberate discussions and interventions using self-report instruments, patient interviews, and the use of technological monitoring systems. Self-reports of behaviors and habits around adherence can be gathered using questionnaires or patient interviews. Patient interviews can include a conversation between the provider and the patient focused on challenges that might arise with adherence and follow through. Interviews would be given before the patient begins an intervention along with subsequent check-in interviews. Use of technology to track adherence to medication or intervention specific activities/homework is also useful. By asking patients targeted questions about adherence, providers can better understand the context around low adherence. These options can improve adherence but also open communication channels between patients and providers.
Patient education given by the provider is commonplace for many interventions, but an open discussion about challenges they might run into related to adherence is essential. A patient who is aware and can anticipate non-adherence behaviors and challenges is more likely to have better outcomes. All these approaches benefit from the patient having an understanding that adherence is complex and related to development of new habits focused on the intervention. In essence, these are adherence interventions.
Recommendations for Researchers
- Considering adherence interventions as important components of all behavioral health interventions.
- Specific attention linking behavior changes needed to optimize adherence should be incorporated into the assessment process. Ask probing questions before sessions to gauge possible treatment adherence challenges and provide suggestions for increasing and maintaining habit changes.
- Carefully capturing adherence related behaviors can increase positive behavioral health habits. This phenomenon is referred to as assessment reactivity. When behaviors and habits (including challenges and possible solutions to increase them) are continuously monitored, individuals become more aware of them, and this can help increase adherence.
- Finally, when disseminating information about evidence-based treatments, research studies need to include specific details related to barriers and beliefs associated with adherence. This can help understand challenges and successes around patient follow through. Unfortunately, many research studies are often silent on these details.
Recommendations for Providers
- Have an open discussion about potential challenges around adherence. This should go hand-in-hand with patient education.
- Open dialogue about common challenges with adherence can open communication channels and reduce stigma, especially for behavioral interventions that require habit modification and self-management.
- People need to have non-judgmental discussion about adherence behaviors and personalized lifestyle modifications with their providers to optimize consistent follow-through.
- Consider adaptations than are in line with the patient’s culture, current lifestyle and circumstances (such as inflexible work schedules).
- Bring in nurse providers or other assistants to share information about health literacy with an intentional focus on adherence and possible challenges. As described by Eunice Zhang in a previous TMCB post, lifestyle and behavior modification should be the center of these ongoing discussions.
Above all, research on medication adherence suggests that adherence interventions for prevention and treatment must be multifaceted, individualized, and continuous to be effective. We recommend adherence-focused interventions as key components of all behavioral interventions. Linking health literacy components to adherence are small steps that can have a large impact on patient outcomes. Other benefits include enhanced communication between patients and providers and reducing mental health-related stigma.
Sebastian Rodriguez
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