Pill reminders: Adressing non-adherence owing to forgetfulness
- Medication adherence is an important factor that determines the treatment efficacy for any disease
- Forgetfulness is the most commonly reported unintentional cause of non-adherence
- Reminder systems are effective in counteracting forgetfulness; however, it is more efficient for patients who remain motivated to take their treatment
- Combining reminders with other adherence modifying strategies has the potential to cater to intentional causes which are often hidden behind the forgetfulness1-3
Medication adherence is defined by the World Health Organization as “the degree to which the person’s behavior corresponds with the agreed recommendations from a health care provider”2. World Health Organization (WHO) suggests that patients are considered adherent if they take 80% of their prescribed medicines4. There are different stages of treatment where non-adherence can occur. Firstly, during treatment initiation, where patients may decide not to start their treatment at all. This is followed by the treatment implementation stage, where patients may use prescribed treatment suboptimally or not follow the medication schedule. Lastly, patients may stop treatment prematurely, leading to premature treatment discontinuation5.
Impact of medication non-adherence:
Medication non-adherence is not just consequential for patients and their families, but also has wider implications for the healthcare system. Studies suggest that adherence to therapies averages 50-70% in high-income countries, while, it ranges from 30-50% in low-income countries6. Low adherence rates worsen health conditions increasing the need for prolonged care, and can even result in death2. It also leads to waste of medication as well as increased use of medical resources such as nursing homes, hospital visits, and admissions2. Therefore it is a significant economic burden on healthcare systems. As per reports the morbidity and mortality associated with sub-optimal medication usage costs around $100 to $290 billion in the US, €1.25 billion in Europe, and approximately $A7 billion in Australia7.
Forgetfulness: Most common cause of medication non-adherence
Patients often report forgetfulness as the cause of non-adherence. As per one report forgetfulness was the reason for non-adherence in 22-73% of patients1. It is major reason for non-intentional non-adherence, a passive behavior that stems from difficulty in following complex regimens, poor memory, or poor recall of prescription instructions4. Intentional non-adherence is a process in which the patient actively decides not to use treatment or follow treatment recommendations. It is a rational decision-making process based on patients beliefs and level of cognition aided by skepticism about medication usage, side effects, long-term efficacy, and fear of drug dependency4.
Non-adherence with elderly people is often caused by forgetfulness and is believed to be mostly unintentional. Younger adults can also forget their medication unintentionally owing to their busy lifestyles1. Notably, adherence rates are generally lower among patients with chronic conditions implying a direct correlation between forgetfulness behavior and the duration of therapy2.
Reminder systems for improving medication adherence
Various forms of reminders are available to patients to tackle forgetfulness. These reminders are primarily based on the principles of behavioral learning theory. The theory of behavioral learning proposes that behavior can be modified after sufficient repetition of external stimulants such as reminders1.
Reminders can be broadly classified into passive and active reminders. Passive reminders such as reminder packaging or pill boxes have reported modest improvements in adherence to chronic disease medications. On the contrary, active reminder systems such as electronic reminders are gaining traction and have shown positive effects on adherence rates1. Some commonly used reminder systems are listed below (Table 1):
- Reminder audio/video phone calls: These are the direct reminders given by healthcare professionals to the patients over audio or video communication. Research shows that they are effective in the short term and could be combined with alternative strategies for optimal result3.
- Short Message Service (SMS): Given high mobile device penetration, SMS reminder is being increasingly implemented for improving medication adherence. A study reports a 90% decrease in the rate of missed doses with the help of SMS reminders8.
- Reminder packaging: Special drug packaging, such as weekly boxes or single-dose blisters with an indication of day and time can also help in improving adherence by facilitating the organization and intake of medicines9.
- Electronic medicine box: Electronic medicine box keeps a detailed record of drug intake by registering the date and time the box was opened. It also offers the opportunity to send an SMS if the patient does not open the box within a certain time frame. Research shows improvement in adherence with real-time monitoring combined with SMS reminders4.
- Automatic pill dispensers: These are computer-based systems that can enhance adherence by performing various functions, such as alarms, sorting medications into compartments, and dispensing the correct dosage8.
- Digital pill: This novel drug-device technology uses “smart” pills with an embedded sensor that helps in tracking the drug status in real-time using a simple mobile application. These devices are currently undergoing further review relating to ethical and safety concerns11.
- Health Apps: There is an abundance of health apps available to patients which aims at improving medication adherence through audio/video alarms and notifications. Research shows improvement in medication adherence in patients using medication reminder apps12. For more information on mobile apps for medication adherence, see our article – Mobile apps to improve adherence to chronic diseases.
Table 1: Advantages and disadvantages of commonly used reminder systems
|Audio/video phone calls||Direct monitoring||Human resource intensive|
|SMS||Simple, inexpensive, personal||Scope of misinterpretation, Reading difficulties for poor vision patients8|
|Reminder packaging||Simple, moderately resource intensive||Supports mainly unintentional non-adherence9|
|Electronic medicine box||Real-time monitoring||Access to a cell phone.|
Cost of the technology10
|Automatic pill dispensers||Standalone device, gives alarm to the patient and can connect to HCPs||Expensive8|
|Health Apps||Inexpensive, simple, variety of functions, accessible||Require digital literacy, smartphone, and internet connection12|
Do reminders work- a glass half full or half empty?
Clinical research suggests a positive correlation between reminders and the rate of medication adherence3. However, there is a dearth of quantitative measurement data in this regard owing to differences in measurement methods. For instance, some researchers use electronic tracking devices to monitor medication use, while others rely upon self-reporting and dose count, which are likely to overestimate adherence data3. Therefore adherence reported from such studies cannot be compared with each other to assess the superiority of the respective interventions. This is a major impediment in assessing the usefulness of reminder tools.
The success of reminders is also dependent on other complex determinants of medication usage, such as medication type, patient population, or disease process. Reportedly, reminders are more effective in patients displaying highly motivated medication-taking behavior3. Therefore, incorporating behavioral counseling to enhance patients’ motivation along with reminder interventions is proposed to work better in lowering non-adherence.
Forgetfulness is one of the key barriers to medication non-adherence. This behavioral folly could be potentially remedied using various reminder systems. Reminder technology has evolved from passive methods to electronic and automated systems1. Numerous studies have found these reminder systems to have a positive correlation with the improved adherence rate. However, in the longer term, adherence may not improve if these systems do not address the underlying reasons behind low adherence3. Overtime, patients also lose interest in reminders, especially if there is a lack of motivation or in the case of intentional non-adherence. Thus, further research is needed to understand what types of reminders are effective for different patients and disease types and how much improvement in adherence is sustainable over time. Moreover, there has been plenty of ongoing research on other types of adherence-modifying strategies, as well as combination strategies, personalized approaches, and cost-effectiveness for widespread implementation.
- Vervloet M, Linn AJ, van Weert JC, de Bakker DH, Bouvy ML, van Dijk L. The effectiveness of interventions using electronic reminders to improve adherence to chronic medication: a systematic review of the literature. J Am Med Inform Assoc. Sep-Oct 2012;19(5):696-704. doi:10.1136/amiajnl-2011-000748
- Jimmy B, Jose J. Patient medication adherence: measures in daily practice. Oman Med J. May 2011;26(3):155-9. doi:10.5001/omj.2011.38
- Fenerty SD, West C, Davis SA, Kaplan SG, Feldman SR. The effect of reminder systems on patients’ adherence to treatment. Patient Prefer Adherence. 2012;6:127-35. doi:10.2147/PPA.S26314
- Hugtenburg JG, Timmers L, Elders PJ, Vervloet M, van Dijk L. Definitions, variants, and causes of nonadherence with medication: a challenge for tailored interventions. Patient Prefer Adherence. 2013;7:675-82. doi:10.2147/PPA.S29549
- Enrica Menditto, Caitriona Cahir, Sara Malo, et al. Persistence as a Robust Indicator of Medication Adherence-Related Quality and Performance. Int J Environ Res Public Health. 2021 May 3;18(9):4872. doi: 10.3390/ijerph18094872.
- Zabihallah Ahmadi HS, A. Hassanzadeh. Evaluation of medication adherence and its relevant factors among hypertensive patients: A cross‑sectional study in Shahrekord health‑care system. Journal of Education and Health Promotion. 2022;11:223. doi:10.4103/jehp.jehp_1332_21
- Cutler RL, Fernandez-Llimos F, Frommer M, Benrimoj C, Garcia-Cardenas V. Economic impact of medication non-adherence by disease groups: a systematic review. BMJ Open. Jan 21 2018;8(1):e016982. doi:10.1136/bmjopen-2017-016982
- Fang KY, Maeder AJ, Bjering H. Current Trends in Electronic Medication Reminders for Self Care. Stud Health Technol Inform. 2016;231:31-41.
- Boeni F, Spinatsch E, Suter K, Hersberger KE, Arnet I. Effect of drug reminder packaging on medication adherence: a systematic review revealing research gaps. Syst Rev. Mar 24 2014;3:29. doi:10.1186/2046-4053-3-29
- Haberer JE, Musiimenta A, Atukunda EC, et al. Short message service (SMS) reminders and real-time adherence monitoring improve antiretroviral therapy adherence in rural Uganda. AIDS. May 15 2016;30(8):1295-300. doi:10.1097/QAD.0000000000001021
- Martani A, Genevieve LD, Poppe C, Casonato C, Wangmo T. Digital pills: a scoping review of the empirical literature and analysis of the ethical aspects. BMC Med Ethics. Jan 8 2020;21(1):3. doi:10.1186/s12910-019-0443-1
- Peng Y, Wang H, Fang Q, et al. Effectiveness of Mobile Applications on Medication Adherence in Adults with Chronic Diseases: A Systematic Review and Meta-Analysis. J Manag Care Spec Pharm. Apr 2020;26(4):550-561. doi:10.18553/jmcp.2020.26.4.550