Overcoming barriers to medication adherence: a comprehensive guide

• Nonadherence to therapies in chronic diseases is a global concern, impacting health and productivity, with 20% to 80% of U.S. patients not following prescribed medical therapies.¹
• Trust and satisfaction between patients and providers, encompassing physicians, pharmacists, nurse practitioners, and physician assistants, along with effective communication about medications, are crucial factors in the medication adherence.¹
• Medication adherence in patients is shaped by factors such as health beliefs, cognitive abilities, demographics, coexisting medical conditions, and medication specifics like regimen complexity and side effects.¹
• Provider factors influencing medication adherence encompass patient-provider trust, communication quality, and the roles of physicians, pharmacists, nurse practitioners, and physician assistants in the medication process.¹

Medication adherence- a global concern

Medication adherence is a critical component of healthcare, particularly when addressing chronic diseases. Nearly 75 percent of American consumers report not always following their prescription medicine as directed. This nonadherence is responsible for significant worsening of diseases, increased mortality, and a surge in healthcare expenses. A 2003 World Health Organization (WHO) report highlights adherence to long-term therapies, emphasizing that nonadherence to medications in chronic conditions is a worldwide challenge with profound effects on health and productivity. In the context of the United States, studies have shown that an estimated 20 percent to 80 percent of patients do not stick to their medical therapies.¹

The public health issue of poor medication adherence

Poor medication adherence is a significant public health issue. Failure to adhere to recommended medication regimens has severe consequences for patients, providers, health plans, employers, industry, and society. Reviews have shown that complex regimens with frequent doses and higher cost-sharing lead to worsened medication adherence. Health-reform discussions in the United States highlight the poor return on investment from the vast amounts spent on health care.¹

Tackling the issue of non-adherence: a multifaceted challenge

Improving medication adherence is a challenging endeavor given the myriad of factors that come into play. The World Health Organization emphasizes the significance of medication adherence for the effective management of chronic diseases. Factors influencing adherence can be categorized into intentional and unintentional aspects. Intentional nonadherence is driven by the patient’s knowledge, motivation, or beliefs about their illness or treatment, while unintentional nonadherence often stems from unplanned behaviors or factors beyond the patient’s control, such as age.²

Types of non-adherence

Medication non-adherence is classified into two types: intentional and unintentional.

1. Intentional non-adherence occurs when patients consciously decide not to follow their prescribed regimen due to beliefs about their illness or concerns about side effects.²
2. Unintentional non-adherence is when patients inadvertently fail to follow their treatment due to factors like forgetfulness, confusion, or external circumstances like financial constraints. Understanding these types can guide healthcare professionals in developing effective strategies. Addressing intentional non-adherence may involve patient education to correct misconceptions, while unintentional non-adherence could be managed by simplifying regimens or providing reminders.²

To read about how to measure adherence is covered in our article – Measuring adherence – an “Achilles heel” in medication adherence

Understanding barriers to medication adherence

Medication adherence, defined as taking at least 80% of the prescribed doses, is a challenge faced by many patients. It’s worth noting that non-adherence can also manifest as overdosing. The implications of not adhering to medication regimens are severe, leading to increased risks of poor health, adverse clinical outcomes, and even mortality. The gravity of the situation is further emphasized by the fact that even low adherence to placebo treatments has been linked to a higher risk of death, termed the ‘healthy adherer’ effect. This highlights the importance of addressing medication adherence, not just for the direct benefits of the medication but also for the overarching positive health behaviors. The goal is to optimize patient outcomes and ensure that investments in health research and care are not squandered.³

Understanding these types of non-adherence is crucial for developing effective patient adherence strategies. However, barriers to adherence are multifaceted, encompassing patient-related factors, healthcare provider factors, medication-related factors, and healthcare system factors.

A. Patient-related factors: include poor knowledge of the illness and medication, difficulties with administering and dosage of the medication, fear towards drugs, and challenges with lifestyle changes.

B. Healthcare provider factors: The challenges include difficulties in reviewing comprehensive medication information, inadequate skills in coaching self-management, and a notable absence of behavioral profiling, which is essential for providing personalized support.

C. Medication-related factors: include complex medications, polypharmacy, and adverse effects.

D. Healthcare system factors: encompass poor access to care, problems with keeping medication lists up-to-date, and IT systems and communication issues within healthcare systems.

An essential approach in healthcare is to identify and assess the underlying factors leading to certain behaviors, such as medication adherence. While various theories and models, like the transtheoretical model of change and the health belief model, have been applied to explain non-adherence, no single model comprehensively addresses the issue. Instead, it’s a combination of factors, including patient perceptions and practical barriers, that influence adherence. Tailored interventions, designed based on these insights, are more likely to be effective than generic solutions. The Beliefs about Medicines questionnaire, for instance, is a recognized tool that captures these factors.^4,5

Practical adherence barriers

Older adults, especially with chronic conditions and cognitive decline, are at a higher risk for poor medication adherence. A systematic review found that those with cognitive impairment had lower medication adherence than their counterparts without such impairment. Interventions tailored to address adherence barriers in these at-risk individuals can enhance clinical outcomes. For instance, to address depression as a barrier to medication adherence in patients with comorbid conditions, studies have examined how integrated care can effectively treat both health issues simultaneously.⁶

Factors contributing to medication underuse

Self-efficacy not only directly impacts medication adherence but also mediates the effects of cognitive and emotional factors like depression and social support. Unintentional nonadherence, often linked to demographics like age, is also influenced by beliefs about illness and self-efficacy. This type of nonadherence is passive and can arise from factors outside the patient’s control. Factors like sociodemographics, illness status, and regimen complexity influence the cognitive components of adherence.²

The impact of low medication adherence on cardiovascular conditions

Low medication adherence can impact the effectiveness of treatments for cardiovascular conditions. As the population ages, multiple chronic conditions and cognitive decline can reduce adherence. Tailored interventions, especially for those at high risk of poor adherence, can enhance clinical outcomes. An integrated care approach, addressing both individual and systemic barriers, is essential for improving medication adherence.⁶

Role of questionnaires in measuring medication adherence

Medication nonadherence is a recognized challenge, leading to suboptimal health outcomes. While numerous tools and questionnaires evaluate medication-taking behaviors, there’s a pressing need to identify the underlying barriers to adherence. These barriers can be broadly categorized into individual and medication-level factors. Individual barriers encompass aspects like self-care ability, the significance attributed to a health event, and knowledge about the condition and its medication. On the other hand, medication-level barriers include beliefs about medication, routines, changes in medication, and the complexity of the treatment regimen. Addressing these barriers is pivotal, as understanding and tackling them can pave the way for improved adherence and better health outcomes for patients.⁷

Overcoming barriers to medication adherence

Medication adherence is vital for health outcomes and guiding healthcare decisions. Poor adherence results in suboptimal outcomes. Recognizing and addressing practical adherence barriers is key to enhancing adherence. Overcoming these barriers often involves straightforward adjustments in the patient’s environment. This emphasizes the importance of tools that measure these practical barriers, as they offer a significant step forward in understanding and improving adherence.⁸

One of the key medical challenges is the lack of holistic management of the patient. The a:care conferences held in 2021 and 2022 were designed to stimulate dialogue among various medical professionals and behavioral science experts, with the goal of promoting a more holistic approach to patient care.⁹

Often, understanding and influencing patient behavior hinges on the interaction of various factors. For instance, the combination of a multifaceted treatment regimen and the existence of comorbid depression can elevate the risk of patient nonadherence beyond the individual impact of each factor. The literature indicates that offering patients educational details about the benefits and potential side effects of therapy is linked to enhanced adherence. This underlines the significance of health literacy in the likelihood of adherence. Yet, determining the best approach to boost patient understanding demands further research.

To address the challenges of medication adherence, it’s essential to deeply comprehend the myriad factors that sway patient behavior, consistently evaluate the risk of nonadherence, and adopt potent strategies to bolster adherence.¹⁰

The role of healthcare professionals

Healthcare professionals, including physicians and pharmacists, play a key role in addressing medication adherence barriers. They improve communication, enhance understanding of diseases, and manage side-effects. They also recommend cost-effective alternatives and simplify regimens. Patient engagement in decision-making is essential. This not only identifies adherence barriers but also promotes patient ownership of their treatment, improving outcomes. Pharmacists offer advice on medication adherence and potential side-effects. Health educators also help in enhancing adherence. Addressing non-adherence involves both educational and behavioral interventions to simplify regimens and enhance understanding.¹¹

There are various technological interventions available that can assist doctors in monitoring their patients’ adherence, sometimes even in real-time. These tools, such as reminders and monitoring aids, can serve as personalized reminders for patients. However, the effective use of these electronic aids demands a certain level of technological proficiency, which might not be attainable for every patient or even some doctors. By integrating education, individualized interventions, and technological tools, healthcare professionals can substantially boost medication adherence, culminating in better health outcomes.¹²

Consequences of medication non-adherence

Improving patients’ understanding of medication benefits and fostering trust in their healthcare providers are essential for enhancing medication adherence. This is particularly important considering that previous studies have highlighted how patients’ worries about side effects, changes in their treatment plans, and communication hurdles can lead to a less-than-ideal relationship between patients and physicians. While trust, communication, and empathy are crucial, they are not readily quantifiable through existing administrative databases. Yet, these elements may significantly impact patient medication practices, shedding light on the complex issue of adherence enhancement. In parallel, it is vital to enhance healthcare providers’ awareness and understanding of patients’ beliefs, concerns, and values, as well as to confront their own potential biases. Given the ubiquity of mobile phones globally, leveraging mobile health technology could be a strategic move. It holds promise for broad impact, offering a practical means to support chronic disease self-management, provide health education, and help patients better adhere to their medication regimens.^{12, 13}

“Medication adherence is a behavior that needs to be understood, not a problem to be solved.” – Dr. Hayden Bosworth, Professor of Medicine, Duke University

References

1. Gellad, W. F., Grenard, J. L., and McGlynn, E. A. A review of barriers to medication adherence: a framework for driving policy options. 2009. Accessed from https://www.rand.org/content/dam/rand/pubs/technical_reports/2009/RAND_TR765.pdf
2. Bae, S. G., Kam, S., Park, K. S., Kim, K. Y., Hong, N. S., Kim, K. S., … and Choe, M. S. P. Factors related to intentional and unintentional medication nonadherence in elderly patients with hypertension in rural community. Patient preference and adherence, 2016;1979-1989.
3. Nieuwlaat, R., Wilczynski, N., Navarro, T., Hobson, N., Jeffery, R., Keepanasseril, A., Agoritsas, T., Mistry, N., Iorio, A., Jack, S. and Sivaramalingam, B., Interventions for enhancing medication adherence. Cochrane Database Syst. Rev. 2014;11
4. Chan, A. H. Y., Cooper, V., Lycett, H., and Horne, R. Practical barriers to medication adherence: what do current self-or observer-reported instruments assess?. Front. pharmacol. 2020;11: 572.
5. Kvarnström, K., Airaksinen, M., and Liira, H. (2018). Barriers and facilitators to medication adherence: a qualitative study with general practitioners. BMJ open. 2018;8(1):e015332.
6. Hennein, R., Hwang, S. J., Au, R., Levy, D., Muntner, P., Fox, C. S., and Ma, J. Barriers to medication adherence and links to cardiovascular disease risk factor control: the Framingham Heart Study. Intern. Med. J., 2018;48(4):414-421.
7. Jamison, J., Graffy, J., Mullis, R., Mant, J., and Sutton, S. Barriers to medication adherence for the secondary prevention of stroke: a qualitative interview study in primary care. Br. J. Gen. Pract. 2016;66(649):e568-e576.
8. Chan, A. H. Y., Vervloet, M., Lycett, H., Brabers, A., van Dijk, L., and Horne, R. Development and validation of a self‐report measure of practical barriers to medication adherence: The medication practical barriers to adherence questionnaire (MPRAQ). Br. J. Clin. Pharmacol. 2021;87(11):4197-4211.
9. Congress overview – a:care Congress 2022. Acare HCP Global. Accessed October 7, 2023. https://acarepro.abbott.com/acare-congress-2022-overview/
10. Seabury, S. A., Gupta, C. N., Philipson, T. J., Henkhaus, L. E., and PhRMA Medication Adherence Advisory Council. Understanding and overcoming barriers to medication adherence: a review of research priorities. J Manag Care Spec Pharm. 2014; 20(8): 775-783.
11. Harmon, G., Lefante, J., and Krousel-Wood, M. Overcoming barriers: the role of providers in improving patient adherence to antihypertensive medications. Curr. Opin. Cardiol. 2006; 21(4): 310-315.
12. Yfantopoulos, J., Protopapa, M., Chantzaras, A., and Yfantopoulos, P. Doctors’ views and strategies to improve patients’ adherence to medication. Hormones. 2021; 20(3):603-611.
13. Brown, M. T., Bussell, J., Dutta, S., Davis, K., Strong, S., and Mathew, S. Medication adherence: truth and consequences. Am J Med Sci. 2016;351(4): 387-399.