Adherence to Long-Term Therapies - Evidence for Action
(2003; 211 pages) View the PDF document
Table of Contents
View the documentPreface
View the documentAcknowledgements
View the documentScientific writers
View the documentIntroduction
View the documentTake-home messages
Open this folder and view contentsSection I - Setting the scene
Open this folder and view contentsSection II - Improving adherence rates: guidance for countries
Close this folderSection III - Disease-Specific Reviews
Close this folderChapter VII - Asthma
View the document1. Defining nonadherence to asthma therapy
View the document2. Rates of adherence to inhaled corticosteroids and other drugs for the prevention of asthma
View the document3. Forms of nonadherence
View the document4. Factors associated with adherence to asthma treatment
View the document5. Adherence in special populations
View the document6. Interventions to improve adherence to asthma therapy
View the document7. Discussion
View the document8. Conclusions
View the document9. References
Open this folder and view contentsChapter VIII - Cancer (Palliative care)
Open this folder and view contentsChapter IX - Depression
Open this folder and view contentsChapter X - Diabetes
Open this folder and view contentsChapter XI - Epilepsy
Open this folder and view contentsChapter XII - Human immunodeficiency virus and acquired immunodeficiency syndrome
Open this folder and view contentsChapter XIII - Hypertension
Open this folder and view contentsChapter XIV - Tobacco smoking cessation
Open this folder and view contentsChapter XV - Tuberculosis
Open this folder and view contentsAnnexes
Open this folder and view contentsWhere to find a copy of this book

6. Interventions to improve adherence to asthma therapy

Haynes et al. (44) recently reviewed the results of randomized controlled trials of interventions to promote adherence to pharmacological regimens across a range of chronic diseases, including asthma, where both adherence and clinical outcome were measured. This rigorous analysis found that over half (10/19) of the interventions for long-term treatments reviewed were associated with significant improvements in adherence; however, the magnitude of the improvements in adherence or clinical outcome was generally not large. The authors concluded that successful interventions to promote adherence were complex and multi-faceted and included combinations of counselling, education, more convenient care, self-monitoring, reinforcement, reminders, and other forms of additional attention or supervision. Specific intervention strategies that can be used for promoting adherence to therapy are outlined below (see also Table 1).

Educational strategies. Asthma is a complex disease and requires education of the patient and his or her family if it is to be managed successfully. Knowledge of the regimen is necessary, but not sufficient in itself, to ensure patient adherence. Several studies have emphasized the central role of effective communication between patients and health care providers in promoting adherence (45,46).

Written instructions about the asthma regimen that are culturally appropriate and adapted to suit the patient's level of literacy should be a core part of every interaction with the patient. For older patients, comprehension and recall of information on how to take medication was shown to be significantly improved when medication-taking instructions were clear, presented as lists rather than paragraphs, used pictures or icons in combination with written medication instructions and were consistent with patients' mental representations of medication taking (47).

Self-management programmes that include both educational and behavioural components have been developed (48). The educational formats use basic learning principles to promote adherence to asthma therapy. Key points in the most recent set of treatment guidelines have included the following:

• education of the patient beginning at the time of diagnosis and integrated into every step of asthma care;

• patient education provided by all members of the team;

• teaching skills for the self-management of asthma by tailoring the information and the treatment approach to fit the needs of each patient;

• teaching and reinforcing behavioural skills such as inhaler use, self-monitoring and environmental control;

• joint development of treatment plans by team members and patients;

• encouragement of an active partnership by providing written self-management and individualized asthma action plans to patients; and

• encouraging adherence to the treatment plan jointly developed by the interdisciplinary team and the patients.

These self-management programmes have demonstrated their effectiveness in decreasing symptoms, school absence and emergency care as well as improving asthma knowledge. However, little is known about the direct effects of these programmes on adherence. Future educational programmes will need to include objective monitoring of adherence in order to examine their effectiveness in promoting it.

Behavioural strategies. Behavioural strategies are those procedures that attempt to promote adherence behaviours directly by using techniques such as reminders, contracting and reinforcement (49). The use of reminders has been shown to be helpful in maintaining adherence both in asthmatic children followed in an asthma clinic and asthmatic children followed as outpatients after inpatient asthma rehabilitation (50,51). Providing feedback to patients regarding adherence to medication is an important behavioural clinical strategy. Informing patients that they will be objectively monitored for adherence has been shown to be effective in improving adherence in outpatient clinics (15), at follow-up visits after inpatient rehabilitation (52) and in clinical trials (53). Reinforcement is an essential component of all behavioural strategies. Reinforcement refers to any consequences that increase the probability of the behaviour being repeated. Dunbar et al. suggested that a clinician's time and attention to the patient may be the most powerful available reinforcer (49). The length of time a patient spends with the clinician is positively related to adherence (54). Investigators have used contracts to include the families of asthmatic children. In this setting patients receive reinforcement from those people who are most significant to them and most readily available at the time the health behaviour occurs (55).

Tailoring of therapy. Tailoring the therapy to the patient is a strategy that is sometimes overlooked by health care providers. Tailoring refers to fitting the prescribed regimen and intervention strategies to specific characteristics of the patient. It is another effective behavioural method used to improve adherence (55).Whenever possible, negotiating a therapy that the patient is able to follow should be a first priority. Some examples of ways in which the therapy may be tailored include exploring the patient's schedule, beliefs, and preferences (56); simplifying the dosing regimen (57); altering the route of administration (58), and using adherence aids (59).

Maintenance interventions to achieve adherence. Achieving and maintaining adherence over long periods of time is difficult for both patients and clinicians. Investigators in the management of childhood and adult asthma have developed self-management programmes to enable a patient and his or her family to manage asthma efficiently and effectively over time in conjunction with their health professional. Self-management programmes for adult and childhood asthma have been shown to reduce asthma morbidity and costs, and may be useful in promoting and sustaining long-term adherence to therapy (60 - 63).

Table 1 Factors affecting adherence to asthma treatment and interventions for improving it, listed according to the five dimensions and the interventions used to improve adherence


Factors affecting adherence

Interventions to improve adherence

Socioeconomic-related factors

(-) Vulnerability of the adolescent to not taking medications; family conflict and denial of severity of disease in adolescents (37); memory difficulties in older patients; polypharmacy in older patients (39); cultural and lay beliefs about illness and treatment; alternative medicines; fear of the health care system; poverty; inner-city living; lack of transport; family dysfunction (40)

List-organized instructions; clear instructions about treatment for older patients (47)

Health care team/health system-related factors

(-) Health care providers' lack of knowledge and training in treatment management and/or an inadequate understanding of the disease; short consultations; lack of training in changing behaviour of nonadherent patients

Education on use of medicines; management of disease and treatment in conjunction with patients (48); adherence education (58); multidisciplinary care (48); training in monitoring adherence; more intensive intervention by increasing the number and duration of contacts (49)

Condition-related factors

(-) Inadequate understanding of the disease (29)

Patient education beginning at the time of diagnosis and integrated into every step of asthma care (48)

Therapy-related factors

(-) Complex treatment regimens; long duration of therapy; frequent doses (32); adverse effects of treatment

Simplification of regimens (57); education on use of medicines (48); adaptation of prescribed medications (55,56,58); continuous monitoring and reassessment of treatment (15, 52,53)

Patient-related factors

(-) Forgetfulness; misunderstanding of instructions about medications; poor parental understanding of children's asthma medications; patients' lack of perception of his or her own vulnerability to illness (31). Patients' lack of information about the prescribed daily dosage/misconceptions about the disease and treatments (29); persistent misunderstandings about side-effects (29); drug abuse (40)

(+) Perceiving that they are vulnerable to illness(31). Self-management programmes that include both educational and behaviour components(58, 60); memory aids and reminders (50); incentives and/or reinforcements (49); multi-faceted interventions, including combinations of counselling, education, more convenient care, self-monitoring, reinforcement, reminders and other forms of additional attention or supervision (44, 65 - 67).


(+) Factors having a positive effect on adherence; (-) factors having a negative effect on adherence.

A group of investigators developed and tested the effectiveness of a psycho-educational self-management programme for severely asthmatic children that was delivered in an inpatient setting (64). Patients were admitted to the programme if they met morbidity criteria in the year prior to admission that included a minimum of three hospitalizations, four emergency visits, four corticosteroid bursts and agreement of the families to participate in self-management meetings. The rehabilitation intervention included medical assessment and management, physical activity training, education about asthma for the child and family, and a sequence of family interviews designed to facilitate home-management of the illness and promote adherence to medication. These individuals were followed as outpatients for 4 years; they received three to four medications concurrently and achieved a marked reduction in hospitalization, emergency care, oral corticosteroid use and total costs of asthma by maintaining adherence, as measured by monitoring theophylline levels at outpatient visits.

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