Nonadherence is a problem that has many determinants; the responsibility for adherence has to be shared by health professionals, the health care system, the community and the patients. Many studies have identified the factors affecting adherence, and these were grouped into five dimensions: socioeconomic- related factors, health care team-/health system-related factors, condition-related factors, treatment- related factors and patient-related factors, as shown in Table 2.
Many factors, such as lack of knowledge about pain management (5,11), misunderstanding instructions about how to take drugs(9), complex treatment regimens (9), anxiety about adverse effects (12), inadequate understanding by health professionals of drug dependence (13) and long distance from the treatment setting, among many others, have been shown to be significant barriers to adherence, and should be taken into account when developing interventions.
Several interventions have been designed to improve adherence to medications for the relief of cancer pain. Some of them target specific factors as described below:
• Patient cooperation. This is achieved by educating the patient about pain and the management of side-effects, and encouraging the active participation of the patient in his or her own pain treatment (9).
• Therapeutic relationship. Good relationships between health professionals and patients should be encouraged (14).
• Simplification of regimens. The use of once-daily, or at most twice-daily, preparations is desirable wherever possible (9).
• Adaptations of prescribed medications. The patient should agree on a medication formulation and medication should be chosen not only for the clinical indication, but also to suit the patient, taking into account his or her lifestyle and preferences (15).
• The role of home care nurses. Home care nurses can play an important role in educating patients and their families about pain management, in administering medications and providing support and counselling (16 - 18).
Failure to address the barriers affecting pain management may lead to therapeutic failure and poor quality of life for the patient.
Table 2 Factors affecting adherence to palliative care for cancer and interventions for improving it, listed by the five dimensions and the interventions used to improve adherence
Cancer |
Factors affecting adherence |
Interventions to improve adherence |
Socioeconomic-related factors |
(-) Long distance from treatment setting |
Optimizing the cooperation between services; assessment of social needs (3); family preparedness (3); mobilization of community-based organizations |
Health care team/health system-related factors |
(-) Lack of knowledge of health professionals about pain management; inadequate understanding of drug dependence by health professionals (5); health professionals' fears of investigation or sanction (19); poor delivery of care education to the patient (20); poor delivery of care education to family and caregivers (20); reluctance of health professionals to prescribe opioids for use at home (20)
(+) Good relationship between patient and physician (14)
|
Training of health professionals on adherence (20); pain education component in training programmes (13); support to caregivers; multidisciplinary care; follow-up consultation by community nurses (20); supervision in home pain management (20); identification of the treatment goals and development of strategies to meet them |
Condition-related factors |
(-) Nature of the patient's illness; poor understanding of the disease and its symptoms |
Education on use of medicine (11) |
Therapy-related factors |
(-) Complex treatment regimens; taking too many tablets (9); frequency of dose; having no treatment instructions (9); misunderstanding instructions about how to take the drugs (9); bad tasting medication; adverse effects of treatment (9); inadequate treatment doses; perceived ineffectiveness (9) unnecessary duplicate prescribing (9)
(+) Monotherapy with simple dosing schedules (9)
|
Simplification of regimens (15); education on use of medications (9); giving clear instructions (9); clarifying misunderstandings about the recommendation of opioids; patient-tailored prescriptions (9,15); continuous monitoring and reassessment of treatment; assessment and management of side-effects; coordination of prescribing (9) |
Patient-related factors |
(-) Forgetfulness (9); misconceptions about pain (11,12); difficulty in taking the preparation as prescribed (9); fear of injections (11); anxieties about possible adverse effects (12); no self-perceived need for treatment (9,21); feeling that it is not important to take medications (9,21); undue anxiety about medication dependence (11); fear of dependence (14); psychological stress |
Interventions to redress misconceptions about pain treatment and to encourage dialogue about pain control between patient and oncologist (9,11); exploration of fears (e.g. about dependence) (9,11); assessment of psychological needs (3); education on use of medications (11); behavioural and motivational intervention (11); good patient - provider relationship (14); self-management of disease and treatment (11,16 - 18); self-management of side-effects (16 - 18) |
(+) Factors having a positive effect on adherence; (-) factors having a negative effect on adherence.
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