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
Open this folder and view contentsChapter XI - Epilepsy
Close this folderChapter XII - Human immunodeficiency virus and acquired immunodeficiency syndrome
View the document1. Types of nonadherence
View the document2. Challenges in assessing adherence
View the document3. Predictors of adherence
View the document4. A framework for interventions to increase adherence
View the document5. Conclusions
View the document6. References
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. A framework for interventions to increase adherence

Experiences with HAART suggest that adherence is arguably the most important issue in successfully managing HIV/AIDs. A multifaceted approach to improve adherence is the most likely to be beneficial, particularly a combination of actively involving patients in their own health care decisions, provision of appropriate supports, multidimensional educational programmes that teach behavioural skills to the patient to enhance his or her adherence, and tailoring of the regimen to fit the patient (13,27,68) (see Table 6).

The provider must accurately assess both the patient's willingness to adhere in the context of possible side-effects, and his or her willingness to overcome potential barriers to taking the medications as prescribed. Furthermore, it is essential that the patient adequately understands the importance of adherence and the serious consequences of nonadherence (i.e. treatment failure, or in some cases, disease progression, drug-resistance or death).

Especially for a condition such as HIV, where poor adherence can cause resistance, it may prove wise to delay active treatment until the patient understands the demands of the regimen and feels truly committed to it. One way in which to gauge a person's readiness to adhere to a regimen, identify specific barriers to adherence, and to simultaneously strengthen the patient - provider relationship is to ask the patient an idea of a trial run of the regimen. This may be done using vitamin pills or jelly beans, with different tablets or different-coloured beans representing the various medications. Such a trial can give patients a perspective on how dosing schedules and other complexities, such as food restrictions or requirements will fit into their daily routine. A trial lasting a few weeks is usually sufficient for assessing a patient's ability to stick to the regimen and overcome the barriers. However, such a trial run is unable to mimic possible side-effects.

For children who rely on the support of caregivers to maintain their adherence, the caregivers must believe the rationale for the regimen and assume responsibility for maintaining it. Moreover, every attempt should be made to involve the children in the decision-making process to the extent of their capability. Although infants may have little influence on adherence, older children can have more influence on whether or not they take their medications as prescribed.

Whether developed or acquired, resistance complicates treatment decisions. As a variant becomes progressively resistant to current medications, the therapeutic options become limited. Then the only solution is to select medications from a new treatment class or prescribe medications from existing classes that have demonstrated efficacy against variants resistant to current medications. However, forced selection limits the ability to fit a regimen to patients' lifestyles and schedules.

Ideally, the health practitioner should work together with the patient to select a regimen that will fit with his or her lifestyle. If more than one regimen may be appropriate for a given patient, providers may want to discuss the regimen, the number of pills, the dosing schedule, instructions and potential side-effects with the patient. This discussion will foster a more collaborative and positive relationship between the practitioner and the patient, which is likely to enhance adherence (68). Once the regimen is decided upon, practitioners must make certain that patients fully understand the dosing schedules and instructions.

Rather than associating doses of medication with times of the day, fitting the regimen to the patient's lifestyle calls for working with the patient to associate medication doses with routine activities performed at the times that the medication should be taken (41). For example, morning doses can be associated with morning rituals (e.g. brushing teeth or reading the newspaper), and evening doses can be associated with evening routines (e.g. children's homework or watching television news programmes). In general it is likely that accomplishing this "fit" will be easier with regimens that require infrequent dosing (i.e. once or twice a day).However, the principle of associating medications with daily activities can also accommodate more frequent and complex regimens.

The most simple, effective and potent regimen will fail if patients experience side-effects that they perceive as problematic and terminate their medications. At the time that the regimen is prescribed, health professionals should be proactive and provide strategies to help patients manage any side-effects that may occur (69). Given that experiencing side-effects is associated with nonadherence, providers and their team members should remain in close contact with the patient during early treatment with a new regimen to allow for the timely identification and management of all side-effects and toxicities. A further advantage of this approach is that it provides an opportunity for reinforcing adherence behaviour. A powerful reinforcer of adherence behaviour is positive feedback regarding medication efficacy (70). Consequently, laboratory and other tests should be conducted soon after the initiation of treatment to show the extent to which it has been effective.

Health care providers and their teams should address the patient-related factors and psychosocial issues associated with nonadherence. While these may vary across conditions, screening for active substance abuse and depressed mood would be appropriate in many patient groups. Finally, enlisting the support of family members and "significant others", or employing "treatment buddies" to administer medications can greatly enhance adherence.

An example of a currently operational comprehensive approach to AIDS care, which includes access to free voluntary tests and counselling, the provision of zidovudine or nevirapine for the prevention of mother-to-child transmission, diagnosis and treatment of opportunistic infections, social assistance and directly observed provision of HAART (DOT-HAART) by trained community health workers to the most severely ill patients, has been implemented by Farmer et al. in a poor rural area in Haiti where HIV infection is endemic (71,72).

Preliminary reports have suggested that adherence rates are almost 100%; 86% of patients have no detectable virus in peripheral blood. Clinical outcomes have been excellent in all patients receiving DOT-HAART, enabling up to 90% of them to resume normal daily activities within 3 months of initiation of treatment. Also, hospitalization rates have decreased by more than half since the start of the programme and a sharp decline in mortality has been observed (73).

The implementation of demonstration projects of good HIV/AIDS care practice, using targeted research or evidence-based quality improvement processes, is urgently needed for effectively fighting against the disease. As Pablos-Mendez stated, "research need not hold back care, we should learn by doing" (74).

Table 6 Factors affecting adherence to therapy for HIV/AIDS 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

(-) Women: stress of childcare (36); low income (49); African American men (63); lack of social support (6)

(+) Support of family and friends (6); Caucasian men (63)

Family preparedness (6); mobilization of community- based organizations; intensive education on use of medicines for patients with low levels of literacy; assessment of social needs

Health care team/health system-related factors

(-) Lack of clear instructions from health professionals; poor implementation of educational interventions (61)

(+) Good relationship between patient and physician; support of nurses and pharmacists (61)

Good patient - physician relationship (61,68); multidisciplinary care; training of health professionals on adherence; training of health professionals on adherence education; training in monitoring adherence; training caregivers; identification of the treatment goals and development of strategies to meet them (68); management of disease and treatment in conjunction with the patients; uninterrupted ready availability of information; regular consultations with nurses/physicians; non-judgemental attitude and assistance; rational selection of medications (62)

Condition-related factors

(-) Asymptomatic patients (32)

(+) Symptomatic patients (32); understanding the relationship between adherence and viral load (53)

Education on use of medicines (53,62); supportive medical consultation; screening for comorbidities; attention to mental illness, as well as abuse of alcohol and other drugs

Therapy-related factors

(-) Complex treatment regimens (28); close monitoring; severe lifestyle alterations (36); adverse events (36); adverse effects of treatment (27); lack of clear instructions about how to take the medications (30,38,40 - 43,53)

(+) Less frequent dose (6,33); fewer pills per day; fewer dietary restrictions (36); fitting medication to individual's lifestyle (35); belief that medication is effective (35)

Simplification of regimens; education on use of medicines; assessment and management of side-effects (37,38); patient-tailored prescriptions (41,68); medications for symptoms (27); education on adherence (68); continuous monitoring and reassessment of treatment (70); management of side-effects (69)

Patient-related factors

(-) Forgetfulness (53); life stress (6,49); alcohol use; drug use (53); depression (6); hopelessness and negative feelings; beliefs that alcohol and drug use interfere with medications (6,64)

(+) Positive beliefs regarding the efficacy of antiretroviral medications (35)

Monitoring drug and/or alcohol use; psychiatric consultation; behavioural and motivational intervention (68); counselling/psychotherapy; telephone counselling; memory aids and reminders; self-management of disease and treatment (68)


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

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