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894 PA R T V / Health Promotion and Disease Prevention
With the advancement of technology, more products and software interventions. They can be divided into four categories: patient-
programs are available for assessing adherence in the person’s natu- related, regimen-related, provider-related, and process-oriented or
ralistic environment. system-related, however, there may be overlap across categories
(Table 40-2). Although some of these factors are not remedial, one
Pill Counts and Pharmacy Refills needs to keep these in mind when developing interventions to im-
prove adherence.
Unique to the assessment of medication-taking adherence, these
measures provide opportunities for alternative or concurrent Patient Related
measurement methods. The pill count is done by tabulating pills
remaining from a previous dispensing for a specific interval, and Self-efficacy for disease management and medication adherence
comparing that number with what should have been remaining. can be significantly affected by several factors, including the pa-
An adherence rate is calculated by dividing the number that tient’s perceived disease severity, 110 self-concept, and the perceived
should have been taken by the number prescribed and multiply- role of medications, for example, taking medication may make a
ing by 100. This method tends to overestimate adherence. An person feel weak or ill. 111 Other factors include prior adherence
early study reported that the pill count rate of adherence was behavior, for example, early appointment canceling, history of not
94%, compared with 84% for the medication event monitor. 35 A following the prescribed regimen, hospitalization for nonadher-
recent study compared the pill count to the four-item Morisky ence; also absence of supportive others and satisfaction with the
questionnaire and reported that the pill count data suggested that provider. 112 Motivation has been identified as an influencing fac-
90% of participants took 80% or more of their study drug while tor; however, the source of motivation (intrinsic vs. extrinsic) for
the Morisky scale showed that 56% reported high adherence and the initiation and maintenance of behavior may vary. 113,114 Two
44% reported medium adherence. 47 A study conducted in Brazil additional factors include skills for implementing the regimen and
showed that neither the pill count nor the Morisky scale had good health literacy. Skills acquisition, for example, learning how to fol-
positive predictive value for adherence. 109 In the age of managed low a complex medication regimen or make prescribed dietary
care and large organizations filling prescriptions, pharmacy refill changes requires that the patient receive training and opportunity
records are commonplace. However, the disadvantage with the pill for practice and feedback before adherence is expected. Health lit-
count and pharmacy record is that they do not provide informa- eracy is necessary for understanding the regimen and for informed
tion on the pattern of adherence, that is, how the individual is tak- decision making. 115 Finally, a factor that has a positive impact on
ing the medication on a daily basis and if the interdose intervals adherence is conscientiousness. 116,117
vary so much that a therapeutic drug level cannot be maintained.
Several factors may influence the pattern of medication taking, for Regimen Related
example, forgetfulness, variations in the patient’s schedule.
A simpler regimen (e.g., fewer medications per day) is associated
Summary with higher levels of adherence in multiple cultures. 46,118 How-
ever, in some circumstances, twice daily dosing may be superior to
Despite the limitations of self-report measures of adherence, there single daily dosing, for example, if an individual misses one or two
remains value in this assessment approach, particularly to com- sequential days of a single daily dose medication, the therapeutic
plement objective measures; however, how the provider poses the concentration in the plasma may be insufficient and the interad-
question is of utmost importance. First, one needs to give the pa- ministration interval may exceed the drug’s duration of action.
tient permission to be nonadherent, and second, one needs to ask One study reported that the probability of missing a single daily
the patient and respond to the patient’s answer in a nonjudgmen- dose was twice as high as the probability of sequential omission of
tal way. Introducing the question with I know it must be difficult a two or three times per day dose. 119 A factor that has been re-
to take all these medicines and to also remember when to take each ported as one of the best predictors of low adherence is medication
one. Often, people forget to take their medications, how often do you side effects. 109
forget to take them? How often do you not take your medicine because
of side effects that you think are related to the medicines? Similar Provider Related
questions can be posed related to diet, physical activity, and smok-
ing cessation. A working alliance, defined as the cognitive and emotional aspect
Because adherence varies over time, ongoing assessment of ad- of the physician–patient relationship showed a strong, positive re-
herence is essential. Moreover, adherence cannot be assumed, nor lationship with the patient’s adherence. 112 Continuity of provider
can the clinician make a clinical judgment that adherence is pres- care and follow-up leads to improved adherence. 11,120 In addi-
ent. Use of one or more of these methods provides the clinician tion, medication adherence can be improved when the provider
or researcher some indication of adherence and possibly infor- clearly communicates the details of the regimen and the expected
mation regarding the circumstances surrounding nonadherence. side effects. 121
In general, it is recommended that more than one method be
used concurrently.
System Related
The frequency at which the prescription needs to be refilled can
DETERMINANTS OF ADHERENCE influence adherence, for example, one study found that patients
with a 60-day prescription of statin reported more adherence than
There are factors that are consistently identified as related to ad- those with 30-day prescription. 122 In contrast, some patients may
herence, and, most importantly, they can be addressed through find the cost of a longer term prescription prohibitive and thus