(2003; 211 pages)
1. What is adherence?
Although most research has focused on adherence to medication, adherence also encompasses numerous health-related behaviours that extend beyond taking prescribed pharmaceuticals. The participants at the WHO Adherence meeting in June 2001 (1) concluded that defining adherence as "the extent to which the patient follows medical instructions" was a helpful starting point. However, the term "medical" was felt to be insufficient in describing the range of interventions used to treat chronic diseases. Furthermore, the term "instructions" implies that the patient is a passive, acquiescent recipient of expert advice as opposed to an active collaborator in the treatment process.
In particular, it was recognized during the meeting that adherence to any regimen reflects behaviour of one type or another. Seeking medical attention, filling prescriptions, taking medication appropriately, obtaining immunizations, attending follow-up appointments, and executing behavioural modifications that address personal hygiene, self-management of asthma or diabetes, smoking, contraception, risky sexual behaviours, unhealthy diet and insufficient levels of physical activity are all examples of therapeutic behaviours.
The participants at the meeting also noted that the relationship between the patient and the health care provider (be it physician, nurse or other health practitioner) must be a partnership that draws on the abilities of each. The literature has identified the quality of the treatment relationship as being an important determinant of adherence. Effective treatment relationships are characterized by an atmosphere in which alternative therapeutic means are explored, the regimen is negotiated, adherence is discussed, and follow-up is planned.
The adherence project has adopted the following definition of adherence to long-term therapy, a merged version of the definitions of Haynes (2) and Rand (3):
the extent to which a person's behaviour - taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.
Strong emphasis was placed on the need to differentiate adherence from compliance. The main difference is that adherence requires the patient's agreement to the recommendations. We believe that patients should be active partners with health professionals in their own care and that good communication between patient and health professional is a must for an effective clinical practice.
In most of the studies reviewed here, it was not clear whether or not the "patient's previous agreement to recommendations" was taken into consideration. Therefore, the terms used by the original authors for describing compliance or adherence behaviours have been reported here.
A clear distinction between the concepts of acute as opposed to chronic, and communicable (infectious) as opposed to noncommunicable, diseases must also be established in order to understand the type of care needed. Chronic conditions, such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and tuberculosis, may be infectious in origin and will need the same kind of care as many other chronic noncommunicable diseases such as hypertension, diabetes and depression.
The adherence project has adopted the following definition of chronic diseases:
"Diseases which have one or more of the following characteristics: they are permanent, leave residual disability, are caused by nonreversible pathological alteration, require special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation or care" (4).