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Non-adherence is one of the most important reasons for the failure of therapies[1]
. In countries where medicines are available for the greater part of the population, improving adherence “may have a far greater impact on the health of the population than any improvement in specific medical treatments”[2]
. Optimal medicine adherence can be summarised as the following[3]
:
- The intake of the right medicine;
- At the right time;
- In the right dosage;
- For the prescribed duration;
- Without adding any uncontrolled self-medication.
Optimal implementation and persistence of therapy will help patients attain better clinical outcomes and improve their quality of life.
Reasons for non-adherence
Non-adherence can be intentional (i.e. the patient does not start the therapy because they do not accept the diagnosis or they change the dosage, etc.) or non-intentional (i.e. the patient forgets to take the medicine as prescribed or the dosing regimen is too complicated for the patient’s abilities)[4],[5]
. Patients may be intentionally and non-intentionally non-adherent at the same time for different medicines.
Reasons for non-adherence are manifold and involve both patients and healthcare professionals. For the patient, factors such as no longer experiencing symptoms, lack of health education or a lack of confidence in the treatment play a major role, along with drug-related problems and possibly high therapy costs. Furthermore, concomitant depression of many patients with chronic diseases might be an underlying, and therefore untreated, issue[6]
. For example, the incidence of depression is twice as high in patients with cardiac disease compared with the general population (9.3% vs. 4.8%)[7]
and non-adherence is higher in patients with depression than in patients without depression (40% vs. 16%)[8]
. For healthcare professionals, lack of time and remuneration might leads to poor communication with patients.
Non-adherence is more likely to occur during transition of care[9]
or situations involving change, such as weekends and holidays or during acute illness, and results in waste of medication[10]
, illness aggravation, hospitalisation[11]
and decreased quality of life[12]
. Subsequently, the annual costs of non-adherence are high[13]
. In this respect, the pharmacist must tailor interventions to the individual patient in addition to their standardised, structured consultation[14]
.
Patient determinants
According to the World Health Organization, there are five sets of factors that affect adherence, of which patient-related factors are only one element[2]
:
- Social and economic-related factors (e.g. poor socioeconomic status, low level of education and unemployment);
- Healthcare system/healthcare team-related factors (e.g. poor medication distribution systems and overworked healthcare providers);
- Therapy-related factors (e.g. duration of treatment, previous treatment failures and the immediacy of beneficial effects);
- Condition-related factors (e.g. severity of symptoms, level of disability and availability of effective treatments);
- Patient-related factors (e.g. disbelief in the diagnosis, forgetfulness and low motivation).
The Theoretical Domains Framework identified 14 domains of theoretical constructs that can be used to simplify the behavioural problems associated with adherence[15]
. Within these domains, Allemann et al. differentiated modifiable determinants (e.g. knowledge and behaviour) from unmodifiable determinants (e.g. age, financial situation and level of education)[14]
. According to their results, adherence interventions should address the modifiable patient determinants and be tailored to the unmodifiable ones. For example, patients who are failing to adhere to their medicine because of social influences (e.g. disrupted family structure) may benefit from family intervention or group programmes.
Pharmacist interventions
Many interventions conducted by pharmacists have been developed[16],[17]
and new services have been implemented, such as medication reviews, medication management and enhanced patient counselling[18]
. Although pharmacist interventions have been structured to fit into daily practice[19]
, medication adherence remains an unsolved issue, even within clinical trials[20]
.
Community pharmacists are the last healthcare professionals that patients will see before using their medicine and, therefore, this may have an impact on their perception of the therapy. Pharmacists can influence patient expectations depending on whether they are confident that the treatment is effective and are able to communicate enthusiasm[21]
(see Box 1). Since community pharmacists see patients face to face, they often get an undistorted picture of the patient’s condition, including dexterity, vision and cognition.
Box 1: Example of how pharmacists can either reinforce (A) or not reinforce (B) the choice of treatment
(A) Physician’s choice is reinforced
Patient: “My doctor has prescribed me this drug. Is it any good?”
Pharmacist: “Absolutely. However, there are a few things to consider to ensure you get the best from it, which I’m sure you will. Can I ask you some questions?”
Patient: “Yes, sure.”
Pharmacist: “What do you already know about the medicine?”
(B) Physician’s choice is not reinforced
Patient: “My doctor has prescribed me this drug. Is it any good?”
Pharmacist: “Let me see. I don’t know, I’ve never heard of it before — it’s not that common. I could double check for you, if you like?”
Patient: “Yes, please do that. I’ll ask you next time, maybe.”
Pharmacist: “You’re welcome. I can look into it next week.”
Trust in the healthcare professional and the healthcare system is important for adherence to medicine and for optimum health outcomes[22]
. Meetings between healthcare professionals and patients can increase trust, if conducted properly. Trust involves the following[23]
:
- Fidelity — caring and advocating for the patient’s interests or welfare and avoiding conflicts of interest;
- Competence — having good practice and interpersonal skills, making correct decisions and avoiding mistakes;
- Honesty — telling the truth and avoiding intentional falsehoods;
- Confidentiality — proper use of sensitive information.
Even though pharmacy consultations might be of short duration, building trust is a prerequisite of every successful discussion with a patient. In general, pharmacists only have a few minutes per consultation; however, this can be enough for a targeted intervention since merely having more time does not guarantee a good consultation[24]
. To be efficient, healthcare professionals must use every minute of the encounter in a motivating, patient-centred way. Each consultation must be well prepared and motivational aspects need to be taken into account. Saying the right things is not sufficient — they must be said in the right manner, so the patient feels motivated.
Effective communication with patients
In its 2018 report on the role of pharmacists in promoting adherence, the International Pharmaceutical Federation identified three overlapping elements of all successful settings and interventions[25]
:
- All members of the healthcare team communicating effectively with the patient and carer ;
- Making it as easy as possible for older patients to take their medicines correctly;
- Sustaining the effort, as no intervention is self-sustainable.
The majority of patients (79%) prefer having an active role in decision making[26]
, and joint goal setting is one of the major determinants of a successful intervention[27]
. Once the patient is actively involved in taking responsibility for their own treatment, the healthcare professional may find that the patient needs social support.
Assessment of adherence and non-adherence
When treatment resistance has been observed, but no obvious cause has been identified, it is important to assess medicine adherence before the therapy is changed to avoid therapy escalation[28]
. Pharmacists and healthcare professionals can use a variety of different methods to assess adherence. For example, direct adherence measures, such as laboratory tests or swallowing a medication that is attached to an ingestible chip, can prove whether the medicine was taken. These are reliable but not the most practical options. Indirect measures, such as questionnaires, are cheap and easy to use[29]
, while electronic monitoring is the most objective measure[30]
(and should be used in preference to questionnaires).
Role of the pharmacist
Adherence measures should not be used to control patients, but rather to unveil errors; therefore, the pharmacist should develop a participative behaviour rather than an authoritarian one. Non-adherence is a complex issue and there is no ‘one-size-fits-all’ solution[31]
. The pharmacist needs to understand the patient’s knowledge, motivation and beliefs before starting an intervention[32],[33]
.
A short, three-step intervention — with modifications for those starting a new treatment — is outlined in Box 2[34]
. It starts with trust-building measures where the pharmacist introduces themselves, followed by an assessment of the medication history. Practical difficulties, misunderstandings or problems can be solved at all stages. For new medicine users, knowledge-based aspects dominate the consultation, while motivation is the main issue for persisting on the regimen. Each consultation ends with agreement on a joint goal until the next visit (see Box 3).
The habit of taking medicine on a regular basis can be sustained by the use of adherence aids, such as pill reminder charts, which can be used to assess intake patterns and provide feedback on the patient’s adherence pattern[35]
. These can help identify non-adherence and enable pharmacists to intervene and educate patients on the importance of taking their medicines as instructed. To avoid difficulties and errors, compliance aids should be delivered with any complex therapy (e.g. colour photographs of each oral medicine, with pictorial aids to indicate the medicine’s purpose and time of administration). In case of intentional non-adherence, motivational interviewing becomes more relevant.
With a patient-centred attitude and targeted communication, the pharmacist can help patients to appropriately manage their condition. However, pharmacists and healthcare professionals should keep in mind that changes during a patient’s life will likely affect their medicine management, even if they have taken the drugs for a long time. Therefore, each encounter with patients should be used as a short intervention and to review adherence problems.
Box 2: Example dialogue of a knowledge-based short intervention with a new drug user (Scenario 1) and a motivation-based short intervention for the same patient already on a treatment (Scenario 2). In both scenarios the patient has a problematic attitude towards their anticoagulant medicine.
Scenario 1: Taking a new medicine
Listen to the conversation here
Step 1 – Introduction and trust building
- Pharmacist: “Hello, I’m the pharmacist. How can I help you?”
- Patient: “Hi, I’ve just been in hospital and been given a new prescription and this discharge letter.”
- Pharmacist: “Why don’t we go to our consultation room, so I can explain how to take the new drug. It will take only a few minutes.”
The pharmacist reads through the discharge letter and looks at the prescription.
- Pharmacist: “Can you confirm your full name and date of birth?”
- Patient: “Yes. John Silverman, 14 March 1949.”
The pharmacist reads through the discharge letter and looks at the prescription.
Step 2 – Probing for information and medication history
- Pharmacist: “I just need to ask you a few questions before we talk about your new prescription. Is that OK?”
- Patient: “Sure.”
- Pharmacist: “Do you have any allergies or intolerances?”
- Patient: “I can’t use aspirin because it’s not good for my stomach.”
- Pharmacist: “Do you have any medical conditions?”
- Patient: “Diabetes and high blood pressure.”
- Pharmacist: “What medicines do you currently take?”
- Patient: “I‘ve been taking tablets every day for over ten years. In the morning, I take metformin and the drugs for my blood pressure. And in the evening, I only take metformin. I also took an antidepressant for a while, but then I was feeling better so I stopped taking it because I didn’t want to take so many drugs.”
- Pharmacist: “So now you only take the metformin, lisinopril and bisoprolol? And you have decided to discontinue the escitalopram. Do you take any other over-the-counter drugs, vitamins or supplements?”
- Patient: “I have taken St. John’s Wort every now and then. This helps because it‘s a natural remedy.”
- Pharmacist: “Herbal ingredients, such as St. John’s Wort, can influence the effects of some drugs, but I will explain more on that in a minute. What did the doctor tell you about your new medicine? Did they tell you anything about its effects?”
- Patient: “I was in hospital for two days because I felt so dizzy. The doctor said my heart beats irregularly and this drug makes my blood thinner to prevent clotting. He explained how to take it, but I’m not sure I’ve understood everything. Can you explain it?”
The pharmacist gets the drug pack and hands it over to the patient.
Step 3 – Adherence support for initiation/implementation, including goal setting
- Pharmacist: “Of course. The new drug prescribed by your doctor is called rivaroxaban. It’s a blood thinner. It was prescribed because your irregular heartbeat means you may develop small blood clots in the heart that could migrate to the blood vessels of the brain and cause a stroke. So it protects you from a stroke, even if your heart continues to beat irregularly. The daily dose you should take is one tablet of 20mg. Please make sure to take it with food. If you forget to take the tablet, you should take it as soon as you remember if it is the same day. Otherwise you should simply skip the forgotten tablet and take the next tablet at your usual time. Don’t take two tablets at the same time.”
- Patient: “OK. I might take the tablet just before bed, so I don’t forget.”
- Pharmacist: “Unfortunately, this is not possible. It’s important to take the tablet every day with food. How about taking this new tablet together with your other medications in the morning with your breakfast?”
- Patient: “OK. Can I still take my other tablets the same way?”
- Pharmacist: “Yes, exactly. In addition, you should not take St. John’s Wort any more. It can lessen the effect of the new anticoagulant drug. And if you feel sad or depressed, you should speak to your GP.”
- Patient: “Oh, OK.”
- Pharmacist: “There are a few side effects of your new drug that I need to mention; these side effects are very rare, but if they occur, consult your doctor. These include vomiting blood or having very black stools.”
- Patient: “OK.”
- Pharmacist: “There are other side effects such as gum bleeding and nose bleeding. Using a soft toothbrush will prevent your gums from bleeding and sea salt nasal drops can help prevent nose bleeds. We have these products in the pharmacy if you need them. In addition, you will bruise easily. Make sure to wear solid footwear to avoid falling. You can also reduce your risk of bleeding by keeping your blood pressure within the normal range; reducing your caffeine intake will help with this. It is important to take this drug every day to prevent the formation of clots and to protect against stroke. Do you have any questions?”
- Patient: “Yes — my sister also had a stroke a year ago, since then she has taken aspirin. Why didn’t I get that?”
- Pharmacist: “There are many kinds of clots and, depending on where in the body they occur, a drug can be effective or not. When the clots are formed in the arteries, aspirin is often prescribed. If, however, they occur in the heart or in the veins of the legs, a drug like the one you have been prescribed is more effective.”
- Patient: “OK, now I understand.”
- Pharmacist: “OK, let’s recap what we have discussed. How will you take your new medicine?”
- Patient: “I take one new tablet with the other medicines every morning with breakfast, and I won’t take St. John’s Wort any more.”
- Pharmacist: “Exactly, and what happens if you forget a tablet?”
- Patient: “If I notice the same day, I’ll take it immediately, but I will not double the dose.”
- Pharmacist: “Very good. If you have any further questions, do not hesitate to come back. I would suggest that we talk in one week to check how it is going — what do you think?”
- Patient: “Yes, perfect.”
Box 3: Example dialogue of a knowledge-based short intervention with a new drug user (Scenario 1) and a motivation-based short intervention for the same patient already on a treatment (Scenario 2). In both scenarios the patient has a problematic attitude towards their anticoagulant medicine.
Scenario 2: Repeat prescription
Listen to the conversation here
Step 1 – Introduction and trust building
- Pharmacist: “Hello, good to see you again.”
- Patient: “Hi. I need a refill.”
- Pharmacist: “Sure, has anything changed or do you have any new prescriptions?”
- Patient: “No.”
The pharmacist looks at the prescription.
- Pharmacist: “So, I see this prescription is for you.”
- Patient: “Yes.”
The pharmacist opens the patient’s account.
Step 2 – Probing for information and medication history
- Pharmacist: “John, is it OK for you if I ask a few questions?”
- Patient: “Yes, but as I told you, nothing has changed.”
- Pharmacist: “Do you have any new allergies?”
- Patient: “No.”
- Pharmacist: “I see that you have diabetes, high blood pressure and atrial fibrillation. Do you have any other conditions?”
- Patient: “No.”
- Pharmacist: “OK. Please tell me what drugs you took this morning.”
- Patient: “Metformin and the other ones for the blood pressure. I was also taking the other one, for my irregular heart beat, but that doesn’t seem to work.”
- Pharmacist: OK. How is that?”
- Patient: “Well I took it for quite a while, but the irregular heart beats never stopped, so I decided to drop it.”
- Pharmacist: “That drug doesn’t change your heart rhythm, but it does help you. Since your heart is beating irregularly, blood clots can occur, which means you are more at risk of stroke. Why were you taking it the first time?”
- Patient: “My wife and me, we love to walk. But I was tired all the time. So we thought that I was depressed, but the doctor said I wasn’t and I should use that drug instead. But the irregular heart beats never stopped. So, I stopped using the drug and went back to St. John’s Wort that I couldn’t use together with that drug, but that didn’t help either. Are there any better supplements that I could buy without a prescription?”
- Pharmacist: “I think that you should give this drug that the doctor prescribed one more chance. The irregular heart beats that you are talking about might cause a stroke and they could also be why you feel so tired.”
- Patient: “OK, but I told you that it didn’t work. I would take it if it worked.”
- Pharmacist: “It does work, but it doesn’t stop the irregular beats. It will help protect you from stroke. What do you think?”
- Patient: “OK, I can give it one more try.”
The pharmacist gets the drug pack and hands it over to the patient.
Step 3 – Adherence support for initiation and implementation, including goal setting
- Pharmacist: “Metformin, lisinopril, bisoprolol and rivaroxaban. How are you taking them?”
- Patient: “Metformin in the morning and evening with food. While the lisinopril and bisoprolol are only in the morning. The other one I can’t remember.”
- Pharmacist: “Ah, for that one, please take one tablet with food. The easiest way would be to take it in the morning with your breakfast and the other tablets.”
- Patient: “How long will it take until I know that it helps me?”
- Pharmacist: “This might differ from person to person. Could you try taking it for one month?”
- Patient: “Yes, I will.”
- Pharmacist: “You should stop taking St. John’s Wort too because it can lessen the effect of the anticoagulant drug.”
- Patient: “Yes, I‘m aware of that now. It didn’t help anyway. It’s just my wife, you know. She said that I should try it.”
- Pharmacist: “Of course. It is good to try things out. However, in this case, it is better to stick to the drug as prescribed. Since your wife is having questions, why not bring her here the next time that you come in?”
- Patient: “Yes, I will talk to her and then I will let you know.”
- Pharmacist: “If you have any further questions, don’t hesitate to come back in.”
International Pharmaceutical Federation (FIP) World Congress
The 78th FIP World Congress will be hosted by the Royal Pharmaceutical Society in Glasgow from 2–6 September 2018. This is the first time for nearly 40 years that the FIP World Congress has been held in the UK. Registration is now open and more information on the event can be found here.
Anna Laven will be chairing a session at the congress on 4 September titled ‘Strategies to improve adherence — technology needs communication’.
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