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
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
Close this folderChapter XI - Epilepsy
View the document1. Introduction
View the document2. Adherence to epilepsy therapy
View the document3. Epidemiology of adherence
View the document4. Factors affecting adherence and interventions used to improve it
View the document5. Conclusions
View the document6. References
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
 

4. Factors affecting adherence and interventions used to improve it

Nonadherence is a problem that has many determinants and the responsibility for adherence must be shared by health professionals, the health care system, the community and the patients. Many studies have identified factors affecting adherence, and these have been grouped into the five dimensions described in section II (see Table 5).

- socioeconomic-related factors;
- health care team/health system-related factors;
- condition-related factors;
- treatment-related factors, and
- patient-related factors.


Many factors, such as misunderstanding instructions about how to take the drugs (6,12,20,23,26), combined antiepileptic medication, complex medication regimens (3,12,26,30), forgetfulness (6), duration and previous treatment failures (14), fear of dependence (20), feeling stigmatized by the epilepsy (20), inadequate or nonexistent reimbursement by health insurance plans (19) and poverty (6), among many others, have been shown to be significant barriers to adherence, and should be taken into account when developing interventions.

Contrary to expectations, a study by Mitchell et al. (14) found that frequency and duration of seizures and previous treatment failure, which are usually thought to be valid prognostic indicators of low adherence, did not affect adherence to treatment. Also, the severity of seizures was not significantly associated with any adherence outcome. However, families reporting less parental education, illiteracy, lower income and high levels of stressful life events were more likely to adhere to treatment.

Some interventions have been designed to improve adherence to anti-epilepsy medications. Some of them target specific factors, such as:

- the therapeutic relationship (increasing communication between patient and health professional) (2,15,16,18,19,23);

- giving full instructions about the treatment and discussing the pros and cons of treatment with the patient (19);

- reducing the number of medications and the frequency of doses (3);

- suggesting memory aids, linking doses to events in the patient's daily schedule, and using alarmed watches or pill cases (3,14,16,31);

- motivating patients to incorporate drug adherence into their lifestyles (6,32); and

- providing a regular, uninterrupted supply of medicines in developing countries (33).


Education in the diagnosis and management of epilepsy was found to be effective in improving recruitment of patients into treatment programmes and in improving drug adherence, or markedly reducing nonadherence (5). The use of educational materials, regular interviews, instructions from nurses and physicians about methods of incorporating drug administration into patients' daily lives, a real partnership between physician and patient, and patient self-management of epilepsy treatment, have all been found to improve adherence to AED therapies (6,11,14,16,18). Other helpful measures were: clear information about the treatment, including giving full instructions; discussing the pros and cons of treatment; reinforcing the value of treatment; explaining and repeating the rationale for the regimen; involving the patients in planning their regimens, and explaining the results of medical tests.

Good adherence education may be based on:

- stressing the importance of adherence at the time the therapy is initiated;

- emphasizing the consequences of nonadherence;

- spending adequate time with the patient;

- enquiring about adherence at each visit;

- motivating patients to incorporate drug adherence into their lifestyles; and

- designing and implementing intervention strategies to improve adherence to self-medication.


These latter strategies include simplifying the regimen with careful explanation of the dosing schedule; reducing the number of medications and the frequency of doses; improving the medication routine through cognitive cueing and through structuring the task and the environment; providing the patients with control and choices; suggesting memory aids; linking doses to events in the patient's daily schedule, or using alarm watches, calendar packs, pill cases, or specialized dose dispensers.

Encouraging patients to develop their own methods to improve maintenance, after educating them about the nature of epilepsy and the need for long-term therapy, may help them to incorporate drug administration into their daily lives. It is important to note that patients from different cultures require different educational approaches to improve adherence (15). In developing countries it is necessary to maintain a regular, uninterrupted supply of medicines (33), to provide drugs at subsidized costs and to organize effective distribution systems (27).

Table 5 Factors affecting adherence to treatment for epilepsy and interventions for improving it, listed by the five dimensions and the interventions used to improve adherence

Epilepsy

Factors affecting adherence

Interventions to improve adherence

Socioeconomic-related factors

(-) Long distance from treatment setting (27); under 60 years old (12,20); teenagers (20); poverty (6); illiteracy (6); unwillingness to pay the cost of medicines (6,23,27); high cost of medication (21,34); local beliefs or beliefs about the origin of illness (6,27).

(+) Elderly patients (over 60 years old) (20); children from family reporting less parental education (14); non-English speaking in an English-speaking community (14); lower income (14); recent immigrants (14).

Assessment of social and career needs (3)

Health care team/health system-related factors

(-) Inadequate or non-existent reimbursement by health insurance plans (19); irregular or poor drug supply (27); lack of free medicine supplies (33); poorly developed health services (27); lack of education about AEDs (21,26,34,35).

(+) Good relationship between patient and physician (20)

A regular, uninterrupted supply of medicines in developing countries (33); good patient - physician relationship (6,11,14,16,18); instruction by nurses and physicians about methods of incorporating drug administration into patient's daily life; training health professionals on adherence; adherence education (11,14,16,19,31)

Condition-related factors

(-) Forgetfulness (6); memory deficits (12); duration, and previous treatment failures (14); high frequency of seizures (14).

Education on use of medicines (5,14,31); suggesting memory aids (3,14,16,19,26,31)

Therapy-related factors

(-) Complex treatment regimens (3); misunderstanding instructions about how to take the drugs (6,12,20,23,26); adverse effects of treatment (6,9,16,20 - 23,27).

(+) Monotherapy with simple dosing schedules (2)

Simplification of regimens; single antiepileptic therapy (monotherapy) (3,16,19,30); education on use of medicines; patient-tailored prescriptions (36); clear instructions; use of educational materials; monitoring and reassessment of treatment (6,11,14,16,18)

Patient-related factors

(-) Disbelief of the diagnosis (16,22); refusal to take medication (34); delusional thinking (16,31); inconvenience of treatment (21,34); denial of diagnosis (21,34); lifestyle and health beliefs; parental worry about child's health (29); behavioural restrictions placed on child to protect his/her health (29); fear of addiction (20); doubting the diagnosis (20); uncertainty about the necessity for drugs (20); anxiety over the complexity of the drug regimen (20); feeling stigmatized by the epilepsy (20); not feeling that it is important to take medications (20).

(+) Parent and child satisfaction with medical care (29); not feeling stigmatized by the epilepsy (20); feeling that it is important to take medications( 20); high levels of stressful life events (14).

Self-management of side-effects (6,11,14,16,18); behavioural and motivational intervention; education on adherence (6,32); providing the patients with control and choices; assessment of psychological needs (3); frequent follow-up interviews (11,16)

 

AEDs, Anti-epileptic drugs; (+) factors having a positive effect on adherence; (-) factors having a negative effect on adherence.

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