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
Open this folder and view contentsChapter VII - Asthma
Close this folderChapter VIII - Cancer (Palliative care)
View the document1. Definitions and epidemiology of adherence
View the document2. Factors and interventions affecting adherence
View the document3. Conclusions
View the document4. References
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

2. Factors and interventions affecting adherence

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


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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