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890 PA R T V / Health Promotion and Disease Prevention
1,000 mg. In contrast, the reported intake of dietary fiber is at ap-
proximately 50% to 75% of the recommended intake. 18 Results METHODS OF MEASUREMENT
from the behavioral risk factor surveillance system revealed that
50.01% of adults engaged in regular activities and that 13.5% Assessment of adherence needs to be incorporated into each clin-
were physically inactive. 19 In general, white population reported ical encounter. It is important that the clinician separate adher-
being more physically active than black population and Hispan- ence from therapeutic or clinical outcome, which can be affected
ics. The dietary excess and physical activity deficiency rates are re- by a myriad of variables besides adherence. For example, inade-
flected in the prevalence of overweight and obesity in the United quate control of serum cholesterol may be due to inadequate drug
States and other westernized countries; the most recent reports in- dosage, individual variation in pharmacokinetic factors ofdiffer-
dicate a combined prevalence of 66% for the United States. 20 ent drugs, daytime or seasonal variations in measurement values,
The poor rates of smoking has been relatively static with an es- or personalfactors. Conversely, the absence of symptoms or
timated 23.9% men and 18.1% women current smokers in the achievement of goaldoes not confirm adherence. Clinical out-
United States as indicated by National Health Interview Survey. comes are indirect measures of adherence, whereas patient behav-
The highest proportion of smokers were American Indian or iors (e.g., weight loss, exercise, taking the medication) are direct
Alaska Native adults (25%) followed by black (21%), white measures of adherence. Both direct and indirect measures have in-
(21%), and Asian populations (13%). 21 Worldwide more than herent advantages and disadvantages. 31,32 Unfortunately, it is diffi-
one third of the population is estimated to be smokers. 22 Studies cult to measure behavior directly, and thus there is a great reliance
suggest that smoking cessation rates remain low with the majority on self-reportedbehavior. Table 40-1 summarizes the numerous
of self-quitters relapsing within the first 8 days of initial cessation, measurement methods and the advantages anddisadvantages of
and that only about 3% to 5% of self-quitters are able to success- their use.
fully achieve abstinence for 6 to 12 months after initial cessation. 23 Adherence assessment can be conducted through numerous
Among those who participate in a formal treatment program, methods. However, a weakness common to all forms of measure-
relapse during or after treatment is usual and might require ment is a bias toward overestimation of adherence. 31 One of the
treatment several times. 24 reasons for this measurement error is that the periodbeing meas-
The duration of treatment is usually a factor influencing com- ured is usually not representative of the patient’s usualbehavior.
pliance, with an initial decline in adherence observed in the first Researchhas shown that patients’ adherence varies in relation to
year followed by a gradual decline over time. This pattern is ob- the clinical appointment, with adherence increasing immediately
served repeatedly among those participating in long-term pro- prior to and after the visit. 33 An example of this would be the pa-
grams, for example, weight loss programs. 25 The prevention and tient taking medicines very closely to how they were prescribed, or
treatment of CVD requires ongoing management of lifestyle closely following a low-cholesterol eating plan for the 7 days prior
habits and, increasingly, inclusion of pharmacologic therapy, such to the clinic appointment. Thus, when the patient is asked to re-
as aspirin, hyperlipidemic agents, -blockers, or calcium channel port on his or her behavior, the report may be influencedby the
blockers. In the absence of sustained adherence, the benefits of individual’s recollection of the most recent behavior and thus
prevention or treatment cannot be realized. This may be critical overestimates adherence for the longer period. Cramer’s research
31
among patients who have had solid organ transplantation. A also showed that the patient was more adherent in the 7 days fol-
meta-analysis of 147 studies revealed that average nonadherence lowing the appointment, and then adherence again tapered off
rates to immunosuppressants, diet, exercise, and other health care until a weekprior to the next appointment. 34 A variety of meth-
requirements ranged from 19 to 25 cases per 100 patients per ods are available to measure adherence in the clinical setting.
year; failure to exercise was highest among heart recipients. 26 These include self-report, biologic and electronic measures, pill
In the clinical arena, nonadherence at any point in the treatment counts, and records such as pharmacy refills.
continuum poses a threat to satisfactory outcomes. Medication
nonadherence has been associated with increased risk of coronary Self-Report Measures
heart disease, precipitated episodes of heart failure, late organ rejec-
tion among heart transplant recipients, and mortality. The literature Self-report measures consist of interviews, structured question-
emphasizes the mediating effects of adherence on clinical outcomes, naires, and diaries, which can be in either paper-and-pencil or
and the impact nonadherence can have on morbidity and mortality electronic formats. This form of adherence assessment is used
associated with CVD regardless of when it occurs in the treatment most frequently, which is probably explained by its ease of ad-
continuum. 7,12,26 ministration and low cost.
In the research arena, nonadherence affects therapy evaluation
before its introduction into the clinical setting. Incomplete adher- Interviews
ence to the treatment under study underestimates its efficacy, and Interviews, often used in the research setting to assess adherence
the diminished effect reduces the study’s power to detect a differ- behavior at each contact, can easily be conducted in the clinical set-
ence between treatment groups, thus preventing the study from ting. A brief interview scale was developed to assess global medica-
meeting the assumptions of the projected sample size. In this sit- tion compliance among hypertensive patients. The four-item scale
uation, when nonadherence to the study protocol results in di- developed by Morisky and colleagues pertains to areas of omission,
minished effect, additional subjects are required. Furthermore, such as forgetting, being careless, and stopping the medication
nonadherence to the treatment protocol may mask side effects or when feeling better or when feeling worse. The literature would
result in an overestimation of optimal dosage. 1,27–29 Finally, in- suggest that the scale is used more often as a questionnaire.
termittent or varying adherence to the study protocol may reflect Adherence can also be ascertained through a 7-day recall in-
varying adherence to concomitantly prescribed therapeutic terview by asking the patient to report the number of pills and the
modalities, which may affect study outcomes. 30 times at which these were taken for each day of the week before