Nonadherence to treatment is a problem of increasing concern to all stakeholders in the health system. Since the early 1970s, the extent and consequences of poor adherence have been well documented in terms of impact on population health and health expenditure. Poor adherence limits the potential of efficacious treatments to improve patients' health and quality of life. This is a particular problem in the context of the chronic conditions that currently dominate the burden of illness in our society. Across health disciplines, providers experience considerable frustration over the high proportion of their patients who fail to follow treatment recommendations.
Adherence is a behavioural problem observed in patients, but with causes beyond the patient. It occurs in the context of treatment-related demands that the patient must attempt to cope with. These demands are characterized by the requirement to learn new behaviours, alter daily routines, tolerate discomforts and inconveniences, and persist in doing so while trying to function effectively in their various life-roles (108 - 110).While there is no behavioural magic bullet, there is substantial evidence identifying effective strategies for changing behaviour.
Practitioners (and other health enablers) often assume that the patient is, or should be, motivated by his or her illness to follow a treatment protocol. However, recent research in the behavioural sciences reveals this assumption to be erroneous. In fact, the patient population can be segmented according to level-of-readiness to follow health recommendations. The lack of concordance between patient readiness and practitioner behaviour means that treatments are frequently offered to patients who are not ready to follow them. This reflects an understandable bias towards treating the biomedical problem and an under-emphasis on addressing the behavioural requirements of the treatment protocol.
Prochaska (71) argued that people move through stages of increasing readiness to follow recommendations as they develop the motivation and skills required to change their behaviour. The SOC model provides a sensible and clear framework upon which to tailor treatment to patients' needs, and organize the delivery of the range of cognitive and behavioural interventions that are supported by the evidence base. Miller and Rollnick (111) noted that motivation to adhere to treatment is influenced by the value that a person places on following the regimen (cost - benefit ratio) and their degree of confidence in being able to follow it. If either the perceived value of adhering, or confidence, is low the likelihood of adherence will also be low.
First-line interventions to optimize adherence can go beyond the provision of advice. Building on a patient's intrinsic motivation by increasing the perceived importance of adherence, and strengthening confidence by intervening at the level of self-management skills are behavioural treatment targets that must be addressed concurrently with biomedical ones if overall effectiveness of treatment is to be improved. This approach offers a way of increasing the sophistication of the adherence interventions offered to patients. Pharmacists, case managers, health educators and others involved in patient care should be made familiar with these basic concepts. Non-physician providers have an important role to play and an opportunity to dramatically improve health by specifically targeting issues of patient adherence.
In every situation in which patients are required to administer their own treatment, nonadherence is likely. Consequently, the risk for nonadherence for all patients should be assessed as part of the treatment- planning process and their adherence should be monitored as part of treatment follow-up. The traditional approach has been to wait to identify those patients who demonstrate nonadherence and then try to "fix" the problem. The risk for nonadherence is ever present. Interventions based on nonadherence risk-stratification should be offered from the start, as opposed to using a stepped-care approach.
Poor adherence persists largely because it is a complex problem and is resistant to generic approaches to dealing with it. Adherence-promoting interventions are not consistently implemented in practice; practitioners report lack of time, lack of knowledge, lack of incentives and lack of feedback on performance as barriers. Clearly, non-adherence is not simply a "patient" problem. At the points of initial contact and follow-up, providers can have a significant impact by assessing risk and delivering interventions to optimize adherence. To make this way of practice a reality, practitioners must have access to specific training in adherence management, and the systems in which they work must design and support delivery systems that respect this objective. Health care providers can learn to assess the potential for nonadherence, and to detect in their patients. They can then use this information to implement brief interventions to encourage and support progress towards adherence.
Interventions aimed at particular diseases need to target the most influential and core determinants among the various factors. Given available resources, these targets will invariably be the patient and provider, at least in the immediate term. Disease-specific protocols for patients can be tailored to their needs. Practitioner protocols can convey the key requirements for the creation of optimal treatment relationships and behaviour assessment and management skills. Beyond this, the system in which providers work must be organized in such a way as to enable a consistent and systematic focus on adherence. A major focus for future research should be the clarification of the best mode, or modes, of delivering adherence interventions. There are many points of contact with patients and times at which such interventions are required, and delivering them outside the traditional health system may enhance their overall effectiveness.