Shared Decision-Making, Therapeutic Alliance, and Self-Efficacy: Patient Partnership Concepts That Drive Medication Adherence
The quality of the patient–clinician relationship is not a soft adjunct to evidence-based prescribing—it is itself an evidence-based determinant of whether patients take their medications as intended.1 Shared decision-making, patient engagement, patient activation, therapeutic alliance, and self-efficacy each describe a distinct but interconnected dimension of the partnership between patient and clinician, and each has a measurable relationship with medication adherence outcomes in chronic disease.2,3 For healthcare professionals working across disciplines and health systems globally, understanding these constructs precisely—and knowing how to activate them in clinical practice—transforms the consultation from information transfer into a therapeutic intervention.4
What Is the Difference Between Shared Decision-Making, Patient Engagement, and Patient Activation?
Shared decision-making, patient engagement, and patient activation are related but operate at different levels of the patient–clinician interaction with each requiring a different clinical response.3
Shared decision-making (SDM) occurs within a clinical consultation and is where the clinician and patient jointly deliberate treatment options, exchange information about values and preferences, and reach a mutually agreed decision.5 The three-talk model of SDM—team talk, option talk, and decision talk—provides a structured framework for this process.5 SDM requires active elicitation of patient preferences and explicit negotiation of a plan that the patient genuinely endorses. SDM has been linked to improved treatment adherence, greater patient satisfaction, and better alignment between treatment decisions and patient values and preferences.6,7
A treatment plan reached through SDM has a fundamentally different psychological status for the patient than one that was prescribed without their active input—it is experienced as a choice rather than an imposition.7
Patient and family engagement is defined as patient, family, their representatives and health professionals working in active partnership at various levels across the health care system such as direct care, organizational design and governance, and policy making to improve health and health care.3 It extends beyond individual clinical encounters to include how patients seek health information, participate in care planning, interact with health systems, and manage their condition between appointments. Patient engagement operates across a spectrum and is influenced by health literacy, self-efficacy, illness, and the quality of the healthcare environment.3
Patient activation refers to a patient’s knowledge, skills, and confidence to manage their own health.3,8 The Patient Activation Measure (PAM), initially developed as a 22-item instrument and subsequently validated in a 13-item short form,8 operationalises activation across four levels from a scale of 0 to 100: from patients who are disengaged and overwhelmed, through to patients who lack the knowledge and confidence to manage their health, to patients who are beginning to take action but lack confidence and skill to adopt behaviours to support their health and patients who have adopted behaviours to support their health but are unable to sustain them due to life stressors or adversity.9 Higher PAM scores have been associated with better medication adherence, fewer hospital admissions, and improved chronic disease outcomes across multiple conditions.9
The three constructs are complementary.2 A clinician who practises SDM with a patient with low activation must adapt their approach—providing more scaffolding, simpler framing, and more explicit support for decision-making—than they would with a highly activated patient.10 The three patient-clinician interactions lead us to the concept of therapeutic alliance.10-13
What Is Therapeutic Alliance and How Does It Link to Adherence?
Therapeutic alliance refers to the quality of the collaborative bond between a clinician and patient, characterised by agreement on the goals of treatment, the tasks required to achieve those goals, and the affective bond of trust, respect, and mutual regard between them.11,12 The construct originates in psychotherapy research, but has also been studied across other disciplines, where evidence links it to clinical outcomes.11,12
A systematic review and meta-analysis found that the quality of the patient–clinician relationship had a small but statistically significant effect on health outcomes.4 Patients with strong alliance are more likely to disclose concerns about their medication reducing the likelihood of intentional non-adherence, more likely to ask questions that improve their understanding of the regimen thereby reducing unintentional non-adherence and they are more likely to feel that their treatment reflects their values.14
Building Therapeutic Alliance in Clinical Practice
Therapeutic alliance is a relational quality that can be deliberately cultivated through strategies which include:11,12
- Trust and empathy: Engaging with the patient signals that the clinician sees the whole patient not just the condition.13
- Consistency and continuity: Continuity of care fosters trust, enhances communication and contribute to the overall therapeutic process.15,16
- Collaborative goal-setting: Discuss with the patients their hopes and concerns and formulate therapeutic goals together.11,13
- Non-judgmental response to disclosure: Patients are acutely attuned to clinician reactions, thus a response such as “Thank you for telling me; help me understand what’s been happening” preserves the alliance and increases the likelihood of future disclosure.14
These relational skills connect directly to a patient-level construct that powerfully moderates the relationship between alliance and adherence outcomes: self-efficacy.17,18
What Is Self-Efficacy and How Does It Predict Adherence?
Self-efficacy, theorised by the psychologist Bandura, refers to an individual’s belief in their own capacity to execute a specific behaviour in a specific context.17 It is not a personality trait (self-esteem) but a behaviour- and domain-specific judgement: a person’s sense of self-efficacy can provide the foundation for motivation, well-being and personal accomplishment.17
Self-efficacy is consistently found to promote medication adherence across therapeutic areas, study designs, and patient populations.18 In the COM-B system, three different components generate behaviours: psychological and physical capability, motivation and opportunity. These components can be influenced by each other such that an intervention to change one component can lead to changes elsewhere in the behaviour system.19
Meta-analytic evidence supports self-efficacy as a strong predictor of adherence than knowledge alone, reinforcing the principle that knowing what to do is not sufficient for doing it.18,20
Self-efficacy also shapes how patients respond to lapses. Patients with high self-efficacy recover from adherence lapses without permanently discontinuing treatment; those with low self-efficacy are more likely to interpret a lapse as evidence of weakness and disengage from treatment altogether.17
The Four Sources of Self-Efficacy
Bandura identified four primary sources through which self-efficacy is built or eroded:17
- Mastery experiences: Successful past performance is the most powerful source. Start with achievable components, explicitly acknowledge successes, and help patients recognise their own competence.
- Vicarious learning: Observing other patient successfully manage the same treatment builds efficacy. Peer support programmes leverage this mechanism.
- Verbal persuasion: Credible, specific encouragement from a trusted clinician such as “You’ve managed this regimen through a difficult few months; that’s genuinely hard” is more effective than generic reassurance.
- Physiological and emotional states: Anxiety and stress can influence perceived self-efficacy. Addressing these through emotional support or stress management can improve confidence.
Self-efficacy can be assessed informally: “How confident are you that you can take this medication every day, even on difficult days?” using a 0–100 scale, with lower scores associated with higher rates of non-adherence.17
What You Can Do
The following steps are evidence-informed and should be adapted to clinical context, patient population, and local guidelines:
Consult local guidelines and institutional resources: Apply these strategies within the framework of locally approved clinical guidelines and institutional protocols.21n about a:care insight: https://acarepro.abbott.com/tools/acare-insight/.9
Practise structured SDM: Use the three-talk model at the point of prescribing and at significant treatment decision points. The three-talk model of shared decision making is a structured approach to collaborative healthcare decision-making consisting of three key components: Team Talk, Option Talk, and Decision Talk to explicitly elicit patient preferences before proposing options.5
Assess patient activation: Use the PAM or an informal activation-oriented question (“How confident are you in managing your health day-to-day?”) to calibrate the level of support needed in the consultation.8
Build alliance through consistency: Maintain continuity where possible. When unavoidable, communicate explicitly the patient’s adherence profile, values, and any established agreements.16
Elicit and affirm self-efficacy: Ask about adherence confidence and acknowledge past successes.18
Respond to non-adherence disclosures with curiosity: Treat non-adherence disclosure as a relational opportunity. Non-judgmental, exploratory responses preserve alliance and increase the quality of future disclosures.21
Address emotional states that undermine self-efficacy: Screen for anxiety, depression, and side-effect burden as modifiable determinants of low adherence confidence.21
Support peer connection where available: Peer support programmes or patient communities can be useful particularly in patients with low self-efficacy or limited social support.21
Conclusion
Shared decision-making, patient engagement and activation, therapeutic alliance, and self-efficacy each describe a distinct and evidence-supported mechanism through which the patient–clinician relationship shapes medication adherence in chronic disease.1,3,7,11 Together, they constitute a relational infrastructure for adherence that is as important as the pharmacological and structural dimensions of care.1,3,7 These frameworks should be applied within the context of local guidelines, institutional resources, and the individual values and circumstances of each patient.2,3
This article was written with the assistance of generative AI technology and reviewed for accuracy.
Evidence on the time cost of SDM is mixed; well-structured SDM may add only a few minutes to a consultation, particularly when brief elicitation tools or decision aids are used.22 Focused approaches can improve the quality of the time spent with patients without adding significant time.22 Importantly, SDM may reduce consultation time downstream by improving adherence, reducing treatment failure requiring escalation.2 Brief SDM frameworks such the three-talk model are designed for feasibility in real-world clinical workflows.5
Patient activation is a dynamic state rather than a fixed trait and can be meaningfully increased through targeted interventions.9 Evidence from trials using the PAM as an outcome measure shows that coaching, health literacy support, and structured self-management programmes can shift patients to higher activation levels, with associated improvements in adherence and healthcare utilisation.
Activation is changeable and may also decline. Clinicians should treat activation as a current clinical variable to assess and support rather than a fixed patient characteristic.9
Alliance has both moment-to-moment and longitudinal dimensions; meaningful alliance can begin to form within a single encounter through specific communicative behaviours, but its protective effects on adherence are strongest in the context of an ongoing relationship.16 Clinicians meeting a patient for the first time can signal alliance-oriented intent through statements of partnership such as “I want to make sure whatever we decide works for you.”11
Low self-efficacy and low motivation are distinct psychological states that require different clinical responses.17 Low motivation reflects low drive and energy to reach a goal, insufficient valuing of the treatment outcome or ambivalence about the necessity of treatment. Low self-efficacy reflects a belief that the desired behaviour is beyond one’s capacity, even when the outcome is valued.17 Motivational interviewing helps individuals make behavioural changes to achieve a personal goal by reinforcing self-motivational statements by getting individuals to talk about their own desire, ability, reason, need and commitment to change23
Decision aids are evidence-based tools—printed, digital, or audiovisual—designed to help patients understand their options, associated benefits/ harm and clarify values before a shared decision.24 They do not replace clinical consultation but structure the information exchange that precedes it. They are particularly useful for treatment initiation decisions and for patients considering discontinuation. A Cochrane systematic review of over 200 randomised trials found that decision aids improve patients’ knowledge, reduce decisional conflict, and increase participation in SDM; no consistent increase in anxiety was observed.24
Therapeutic alliance has been shown in studies in medicine to influence adherence, satisfaction and quality of life.12 Patients with lower health literacy, higher illness burden, or significant psychological distress may be more dependent on relational quality as a motivational resource, as they have fewer independent cognitive and emotional resources for self-management.3 In populations where healthcare distrust is historically grounded—due to systemic inequities or past negative experiences—alliance-building requires particular sensitivity and consistency over time.16
At initiation, start with a simplified, manageable regimen.25 Discussing the patient’s previous experience to identify existing self-efficacy resources. Simplify medication regimes and providing specific, credible affirmation of capability rather than generic encouragement. Anticipating and pre-addressing likely obstacles—”If you miss a dose, here’s what to do”—builds coping self-efficacy alongside performance self-efficacy.25
The Patient Activation Measure (PAM) is a validated 13-item instrument using a 4-point response format, scored via Rasch measurement to produce a score mapped to four activation levels.8,9 PAM scores guide the level of support provided: patients at lower activation levels benefit from simpler, more structured information and more frequent follow-up; those at higher levels may benefit from greater autonomy and complex self-management support .8,9 Clinicians should be aware that PAM requires appropriate licensing arrangements for use in routine care settings.26
Both SDM and therapeutic alliance are culturally situated concepts, and their expression varies across health systems and patient populations.27 In some contexts, a more directive clinician role is expected and experienced as respectful; in others, highly participatory approaches are preferred. The core principles—eliciting patient values, building trust, and ensuring the patient endorses the treatment plan—remain universally relevant, but the communicative style should be adapted to cultural norms, individual preferences, and health literacy levels. Clinicians working in diverse or multicultural settings are encouraged to seek cultural competency training.27
Self-efficacy and health literacy are distinct but interacting determinants of adherence.18,28 Patients with low health literacy often experience secondary reductions in self-efficacy when they are unable to fully understand their treatment instructions—reinforcing each other as barriers. Interventions that improve health literacy (simplified materials, teach-back) may have downstream benefits for self-efficacy by reducing the cognitive gap between instruction and execution1,.28 Building self-efficacy through patient empowerment improves health and clinical outcomes including medication adherence.18
