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Introduction to Medical Adherence

Method In Improving Medical Adherence

Discussion

Summary

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References

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Introduction
The benefits intended through the use of medications are not fully realized by millions
of people due to non- adherence that's largely undetected. Medical adherence is
defined by the World Health Organization (WHO) as the extent to which a persons
behaviour in terms of taking medications, following diets or executing lifestyle
changes, corresponds with agreed recommendations from the healthcare provider. In
short, medical adherence can be understand as:
Adherence = Compliance (patients behaviour coincides with medical or health
advice +medication consumption as instructed, % pills taken) + Persistence
Medical adherence issue gained significance since the last 40 years. However,
research in this area is still lacking with limited findings. Complicating the issue of
adherence is the fact that the volume of medications used today in health care which
is far greater than that of 40 years ago, making the fundamental issues underlying
adherence more difficult to reach. Whilst, the problems created by non-adherence
progress to worsen with more risk and cost.
In the current study, medical adherence as proposed by Morisky was
operationalized to mean the extent to which patients take prescribed medical
regimens without having the four issues of carelessness, problem in
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remembering taking medications, stop taking when feeling better and stop
taking when feeling worse due to drugs side effects which focus on patientrelated factor. The barrier in achieving medical adherence in a larger scope however
is generally classified by WHO into 5 dimension:
1. Social/economic factors
2. Therapy-related factors
3. Patient-related factors
4. Condition-related factors
5. Health system and healthcare team factors

Method
1. Evaluation of Medical Adherence
Evaluation on how well a patient is adhering to pharmacotherapy and identify risk
factors that may predispose the individual to non-adherence is crucial before
effective, customised strategies can be devised to counteract non-adherence.
However, there is still absent of gold standard method to measure medication taking
behaviour, in which both direct and indirect methods are temporarily in use to assess
adherence. Direct methods involves directly observed therapy which include bloodlevel monitoring and urine assay for the measurement of drug metabolites or marker
compounds. Indirect methods of assessing adherence on the other hand, include
patient interviews, pill counts, refill records, and measurement of health outcomes.
Physicians are encouraged to try more than 1 strategy in detecting adherence in
patient.

2. Strategies in Improving Medical Adherence

Strategies to improve adherence should target the specific risk factors and causes
identified during the patient assessment. Adherence strategy may be used alone or in
combination, but should be tailored to the individual patient. Strategy based on four
Morisky elements and SIMPLE intervention are among the strategies available in
improving medical adherence.
2.1 Moriskys Four Elements Strategy
Adherence is judged based on four main elements in Morisky Medication Adherence
Scales. The four elements includes forgetfulness, carelessness, stop taking when
feeling better and stop taking when feeling worse due to drugs side effects.
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2.1.1 Forgetfulness
Forgetfulness in taking medication can be corrected by using adherence tools such
as compartmentalized pillboxes, medication calendars, post-it note reminders, timers
and even high tech talking devices that sound an alarm when a dose is missed.
Adherence tool though reliable, have chances of malfunction. Manual alertness by
the patient hence is the most practical. Patient alertness can be instilled by setting up
a strategy in which medications is designed to be taken at the same time every day
which fit to their daily routine. The key here is to set up a clockwork pattern of daily
repetition for taking medication.
Forgetfulness can also be prevented or improved by involving the family members.
Family members can be educated with regimen as well as the technique of
administration. Being the closet person to patient, they can help by reminding the
patient while ensuring patient administer medicine in the correct way.

2.1.2 Carelessness
To prevent carelessness in patient, medical provider involved must speak in a
simple and clear manner while emphasizing the information necessary for
compliance early in the communication, and then repeat the same information both
orally and in writing. It is important for medical provider involved to avoid jargon and
always being alert of the term used even simple language. Terms common to the
practitioner, such as "follow-up" and "workup," may very well require explanation or
substitution.
After the briefing, it is encouraged to assess patient on understanding whereby
patient will be required to describe their regimen as well as the technique involved
verbally or through writing. Any misunderstanding spotted should be highlighted and
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corrected. If the patient remain confused after multiple briefing, patients family
members should be asked to be briefed instead.
2.2.3 Unauthorised Termination of Regimen When Symptoms Resides
The Im Cured Syndrome is common among patient whereby they discontinue the
drug prescribed without any medical advice once their symptom remit.
To curb this issue, patient should be alerted by the effect of self-termination of drug
by physician or pharmacist upon dispensing of drug. Patient need to be reminded
that they shouldnt take this matter into their own hands as there is a standard
procedure in terminating the drug and they shall always refer to their physician or
pharmacist for recommendation and advice to prevent adverse effect from their
action. Pharmacist or physician should offer a convenient way for patient to reach
them either by calling or through mail.
2.2.4 Unauthorised Termination of Regimen in Preventing Side Effect
To prevent self-termination of regimen by patient due to side effect, it is important for
physician or pharmacist to be honest with patient about side effects. Try to point out
to patient that every drug has side effects but many of them are short-lived. Discuss
the typical side effects of the medications that the patient is taking, and suggest ways
for combating them. For example, drugs with the side effects of anxiety and
sleeplessness are best taken in the morning. Sedating medications should be taken
at bedtime, and those linked to nausea are to be consumed on a full stomach.
2.2 SIMPLE Intervention Method
SIMPLE intervention involves a set of procedure which is designed in a way that it
includes all five WHO dimension, making it one of the most effective intervention in
combating medical non-adherence.

implify the Regimen

In simplifying a regimen, physician should

adjust timing, frequency, amount, and
dosage of regimen in a way that it is
convenient and match to patients activities
of daily living. To avoid missed doses,
patient should be recommended to take all
medications at the same time of day and to consider the use of adherence aids .If
medication is available in simpler dosage form, medications with special
requirements should be avoided and customized packaging for patients could be
dispensed up to patient convenience.

mpart Knowledge

To improve patient adherence, physician should focus on patient-provider shared decision

making by encouraging the patient to have discussions with physician, nurse, and
pharmacist about the doubt they have. It is also important for physician or pharmacist to
provide clear instructions (written and verbal) for all prescriptions. For better grip in
patient, limit instructions to 3 or 4 major points while using simple, everyday language.
Use written information or pamphlets and verbal education at all encounters and always
attempt to involve family and friends in the discussion when appropriate. Provide quality
web sites for patients wishing to access health education information from the Internet and
brief them on computerized self-instruction available online for complex chronic
conditions. It is also important for physician to provide concrete advice for how to cope
with medication costs. Reinforce all discussions often, especially for low-literacy patients.

odify Patient Beliefs and Behaviour

Physician or pharmacist should empower patients to self-manage their condition by

asking patients about their needs. To understand their need, create an open
dialogue with each patient and ask about his or her expectations, needs, and
experiences in taking medication. Always ensure patients understand they will be at
risk if they dont take their medication by requesting them to re-describe the
consequences of not taking their medication. Reward system could be considered to
further reinforce the change in behaviour of patient.
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rovide Communication and Trust

Modifying patient beliefs is only possible if a high level of patient trust exists. A
physicians communication style is one of the strongest predictors of a patients trust in
his or her physician. It is hence important for a physician to acquire good
communication skill. A physician with good communicating skill has a few qualities
which includes good interviewing skills, practice active listening, provide emotional
support, provide clear, direct, and thorough information, elicit patients input in
treatment decision-making, as well as allow adequate time for patients to ask
questions.

eave the Bias

To prevent from being bias in making decision, physician should learn more about
low health literacy and how it affects patient outcomes, examine self-efficacy
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regarding care of ethnically and socially diverse patient populations, and to

acknowledge biases in medical decision-making. It is also important for physician to
frequency review their own communication style to see if it is patient-centered.

valuating Adherence

The act of measuring adherence is crucial in deciding the effective ways that lead to
better patient compliance. There are 2 ways in measuring adherence which are direct
and indirect methods. Direct method includes directly observed therapy,
measurement of drug concentration in blood and measurement of biologic marker in
the body. On the counterpart, indirect methods include patient self-report, pill counts,
pharmacy fill data, electronic medication monitoring, and assessment of patients
clinical response.

Discussion
The World Health Organization (WHO) states that "increasing the effectiveness of
adherence interventions may have a far greater impact on the health of the
population than any improvement in specific medical treatments. Intervention is
therefore important to be the main focus in healthcare, in which it should be
conducted effective-based rather than just a matter of obligation. Effective
intervention are usually found customised as studies show each non-adherent patient
has a unique set of influencing factors which involve the interplay of the 5 WHO
dimensions.
The main reasons for non-adherence in patient, usually includes perception of
unrealistic goals of therapy (result factor), a lack of immediate visible benefits (time
factor), medication costs, lack of medicinal significance, fear of medication side
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effects, not knowing how to take or use the medication, previous unpleasant
experiences with medications, complexity of medication regimens, cognitive
impairment, and forgetfulness. Personal factors, including lifestyle, culture and belief
system is also the main contributor to non-adherence in patient as adherence rates
and factors are always found vary in different places.
Good adherence towards medications as well as medical advice can help people to
control their health conditions, especially those with chronic diseases which cant rely
on their impaired, natural homeostasis to put them back to normal. Despite knowing
that adhering to prescribed medications are necessary to control health conditions,
medical non-adherence remains a major public health problem that that has been
called an "invisible epidemic. Malaysia, which has hypertension as top killer, have
seen with exceptionally high rates of non-adherence among patient towards antihypertensive regimen, whereby from studies, among 87% of hypertensive patients
who were receiving treatment, only 26.3% of their hypertension was under control.
Medical non-adherence causes treatment failure which increase disease morbidity
and mortality. With every treatment failure, additional expenditure and resource
wastage in the area of health care is at cost. It is estimated that total health care cost
increase two fold with non-adherence in taking medications. With non-adherence
remain unsolved, medical resources will continue to be under-utilized, including
hospitalization of non-adherent patients, which increase burden on health care
workers. Pharmacies also lose revenue because patients often fail to refill
prescription medications, especially for chronic disease

Summary
Effective prevention and solution are always linked to how highly customised or
designed the steps taken are. Evaluation of adherence hence play a crucial part in
the effort of improving patients medication adherence as it lead physician or other
healthcare professional involved to the best, patient- customised strategies. Among
the strategies available are Moriskys four element based factors with corresponding
solution and SIMPLE intervention. SIMPLE intervention which is a set of procedure
involving all five WHO dimension is widely used for its high effectiveness in improving
medical adherence in patient. It is always important to note that one-size-fit approach
is not the best option when effectiveness is the aspiration.

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References
1. Million Hearts () Improving Medication Adherence Among Patients with
Hypertension: A Tip Sheet for Health Care Professionals, Available
at:http://millionhearts.hhs.gov/files/TipSheet_HCP_MedAdherence.pdf (Acces
sed: 15th January 2015).
2. Chang,J.,Tan,X., Isha,P. () Review of the four item Morisky Medication
Adherence Scale (MMAS-4) and eight item Morisky Medication Adherence
Scale (MMAS-8),Available
at:http://www.ahc.umn.edu/innovations/prod/groups/cop/@pub/@cop/@innov
/documents/article/cop_article_483579.pdf(Accessed: 15th January 2015).
3. Chong,S.L.,Yeow,J. () Medical Adherence among Hypertensive Patients in
Malaysia,Available
at: http://www.academia.edu/3697586/Medical_Adherence_in_Malaysia(Acce
ssed: 15th January 2015).

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4. J,A. (2000) Optimizing Adherence to Pharmaceutical Care Plans, Available at:

http://www.medscape.com/viewarticle/406691_2 (Accessed: 15th January
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5. CDC (2013) Medication Adherence, Available
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6. VHQC () Improving Medication Adherence in Older Adults: What Can We
Do?,Available at: http://www.champprogram.org/static/ImprovingMedAdherenceOlderAdultslyer_final_508C.pdf (
Accessed: 15th January 2015).
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action,Available
at: http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf
(Accessed: 15th January 2015).
8. PhARMA (2011) Improving Pescription Medicine Adherence is Key To Better
Health Care, Available
at:http://phrma.org/sites/default/files/pdf/PhRMA_Improving%20Medication
%20Adherence_Issue%20Brief.pdf(Accessed: 15th January 2015).
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at:http://www.todaysgeriatricmedicine.com/archive/0115p12.shtml (Accessed:
15th January 2015).
10. Cheung K, Hicks J, McEwen B, Cianfarani G. (2012) Strong healthcare
provider-patient relationship improves patient adherence and lowers
healthcare costs: a meta-analysis,Available
at:https://www.medcred.com/libs/pdf/healthcare_portfolios_patient_adherenc
e.pdf(Accessed: 15th January 2015).
11. Honigberg R, Gorden M, Wisniewski AC. (2011) Supporting Patient
Medication Adherence: Ensuring Coordination, Quality and
Outcomes, Available at:https://www.urac.org/wp-content/uploads/URACMedAdherence_White%20Paper.pdf(Accessed: 15th January 2015).

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