The COVID-19 pandemic has highlighted the imperative that people should self-manage their long-term conditions as much as possible, both to maximise their own health gain and quality of life, as well as to avoid the unnecessary use of limited healthcare resources at a time when those resources are under increased demand. Many district nursing clients will be taking more than four medicines with different regimens over a long period of time, and, therefore, it is likely that there will be some non-adherence.
A key element of effective self-management of many long-term conditions is adherence to the prescribed regimen, which may include medication at particular times, as well as other self-care activities, such as adequate hydration, a nutritious diet, exercise or physical activities within capabilities and sufficient rest. This article explores the evidence regarding non-adherence and potential strategies to promote adherence, so that district nurses may better understand the factors underlying non-adherence and their clients' perspective as a precursor to supporting their clients' medication needs.
Adherence
Adherence is defined as the extent to which the individual's behaviour or actions match the recommendations agreed with their health professional (National Institute for Health and Care Excellence (NICE), 2009). Non-adherence is a major barrier to the effective delivery of healthcare, and it is estimated that adherence to treatments for long-term conditions averages 50% in developed countries (World Health Organization (WHO), 2003). Non-adherence has been a persistent issue in healthcare, as evidenced by DiMatteo's (2004) analysis of 569 studies reporting adherence to medical treatments, excluding psychiatric treatments, between 1948 and 1998. This study reported an average non-adherence rate of 24.8%, although the figure disguised the wide variation across the included studies. Adherence rates are usually expressed as the percentage of the prescribed doses of the medication actually taken by the individual over a specified period. Adherence rates are generally higher for acute conditions as compared to long-term conditions, with adherence rates dropping most dramatically after the first 6 months of treatment (Osterberg and Blaschke, 2005).
Cutler et al's (2018) systematic review found that medication non-adherence imposed a significant cost to health services accrued through pharmacy costs, in-patient stays, out-patient visits, emergency department visits and other hospital costs, in addition to medication-related harm (Parekh et al, 2020). The Pharmacy Magazine (2017) estimated that non-adherence was costing the NHS more than £500 million a year, in addition to £300 million on wasted medication, which the NHS can ill-afford, especially with the increased costs and service demands of the COVID-19 pandemic.
Jensen and Li (2012) analysed a 1994–2004 dataset from 2460 nationally representative adults aged 50–59 years in the US Health and Retirement Study and found that patients who underused medication(s) due to cost were significantly more likely to report a new chronic condition, be hospitalised, experience a heart attack or stroke and have problems develop that limited their ability to work over the 10 years of the follow-up study. Unlike many countries, the UK subsidises prescribed medication costs, so it is unsurprising that, in a comparative study involving 11 countries, the self-reported cost-related non-adherence (CRNA) in the form of either not filling a prescription or skipping doses within the last 12 months because of out-of-pocket costs among all older adults was low in the UK and varied greatly, from less than 3% in France, Norway, Sweden, Switzerland and the UK to 16.8% in the US (Morgan and Lee, 2017).
Over the years, a range of terms have been used to describe behaviours related to medication. Previously, the term ‘compliance’ was dominant and described the extent to which an individual's behaviour matched the prescriber's recommendations. The term has been replaced by ‘adherence’ because ‘compliance’ implied a lack of patient involvement, passivity and judgement by others. ‘Adherence’ acknowledges that people are free to decide whether to adhere to treatment recommendations and that failure to do so should not be a reason to blame patients (European Patients' Forum (EPF), 2015). ‘Concordance’ is the most recent term and is predominantly a UK term. Over time, its definition has changed from focusing on the consultation process and doctor and patient agreement within therapeutic decision-making to a wider concept that includes prescribing communication, decision-making and patient support regarding therapeutic regimes (EPF, 2015).
Medication-related harm
Medication-related harm among older people has been highlighted by the potential risks associated with polypharmacy (Mortazavi et al, 2016) and includes harms from adverse drug reactions (ADRs), non-adherence and medication errors. Ageing increases the likelihood of multi-morbidity and, therefore, greater drug use and, potentially, polypharmacy. Furthermore, older people are more susceptible to adverse reactions, which, combined with multiple drug use, increases the risk of drug interactions. Although some polypharmacy is appropriate, interventions such as medication reviews by pharmacists are recommended to reduce inappropriate polypharmacy (Patterson et al, 2012) and can identify medication-related difficulties among those living at home (Beuscart et al, 2019).
A case-control study conducted in Sweden explored the relationship between potentially inappropriate medications (which included long-acting benzodiazepines, tramadol, propiomazine and medicines with an anticholinergic effect), number of chronic conditions, medications and the risk of hospitalisation using data from 5720 patients in 2860 risk sets matched on age and gender (Thorell et al, 2019). They found that five to seven conditions and the use of five to nine medicines at the same time increased the risk of hospitalisation, while potentially inappropriate medicines showed no significant association in the multivariate analysis.
Parekh et al (2020) developed a tool that predicts the risk of medication-related harm following hospital discharge, comprising eight variables at discharge, namely, age, gender, anti-platelet drug, sodium level, anti-diabetic drug, past ADR, number of medicines and living alone. The tool is now being tested in primary care to confirm whether it is useful within clinical practice to identify those in need of additional healthcare input.
Reasons for non-adherence
Non-adherence is not explained by personality traits, sociodemographic variables or type or severity of disease. Although providing clear information is essential for adherence, this does not of itself guarantee adherence (Horne et al, 2005). Non-adherence is generally lower with complex regimens, but reducing the frequency of doses does not appear to improve adherence (Horne et al, 2005). Research over the past 15 years has indicated that personal beliefs about the illness and treatment are important, so that what may seem puzzling behaviour from the perspective of the health professional is a rational response within the context of the person's life, reflecting their perceptions, experiences and priorities. Thus, people balance perceived necessity and concerns, which is expressed as adherence behaviour with intentional and unintentional causes (Horne et al, 2005).
Horne et al (2005) drew a distinction between intentional and unintentional non-adherence, with unintentional non-adherence arising when people want to follow a treatment but are prevented from doing so by barriers beyond their control (Table 1). These include individual capacity, such as dexterity, memory and difficulties in understanding instructions, and personal environment, such as access to healthcare and competing demands. On the other hand, intentional non-adherence occurs when an individual decides not to follow the treatment recommendations, reflecting the personal beliefs, attitudes and expectations that underpin their motivation to commence a recommended treatment and persist over time. An understanding of the inter-relationships between unintentional and intentional non-adherence and interventions such as communications between the patient and health professional is a continuing research theme. Furthermore, much of the research examined by Horne at al (2005) was cross-sectional, so that less is known about long-term adherence behaviours and how interventions may increase adherence. It is probable that people's choices change in different contexts and at different stages of an illness.
Table 1. Cases of nonadherence to medication
| Non-intentional causes | Intentional causes |
|---|---|
|
|
A more recent systematic review explored the influence of perceived necessity and concerns about potential adverse effects regarding medication on adherence among those with long-term conditions (Horne et al, 2013). Significantly higher adherence was present among those with stronger perceptions regarding the necessity of the treatment and fewer concerns about the treatment. This relationship was present across study size, the country where the research was conducted and different adherence measurement tools. Horne et al (2013) argued that the necessity-concerns framework aids an understanding of the patient perspective regarding medicines and highlights how health professionals need to take the patient perspective into account when making treatment decisions with patients in order to achieve optimal adherence. Holmes et al's (2014) systematic review of the health psychology literature reported similar factors underpinning adherence, namely, self-efficacy, perceived barriers, perceived susceptibility, necessity and medication concerns.
Maffoni et al's (2020) systematic review of 39 qualitative studies is particularly relevant, with its focus on medication adherence in older adults with chronic multi-morbidity, although few studies looked at the initiation of the treatment phase, with most focusing on the implementation and persistence of the treatment regimen. They found that the patient's beliefs about polypharmacy and drug prioritisation (one or more treatments being more important than others), the patient's experience and capabilities, the prescriber–patient relationship, health literacy, the treatment characteristics and complexity and family and social support mediated adherence. Additionally, with each treatment change, the patient repeats the decision-making, which may result in full, partial or no implementation of the new regimen. Again, this review emphasises the importance of understanding of the patient perspective (Maffoni et al, 2020).
Interventions to improve adherence
NICE (2009) is clear that improving adherence is not about getting patients to take their medicines, per se, despite non-adherence having deleterious effects, both on the individual through lack of health improvement or health deterioration, and wider society through wasted medicines and increased demand for healthcare with health deterioration. Adherence should be based on an agreement between the health professional and the patient, with both fully agreeing a treatment decision; the health professional provides the required support needed by the patient to fulfil the treatment decision. Therefore, non-adherence should not be viewed as the patient's problem.
The latest Cochrane review focusing on adherence (Nieuwlaat et al, 2014) concluded that the effects of the interventions were inconsistent across the 182 studies, with only a minority of methodologically strong randomised controlled trials (RCTs) reporting improvements in both adherence and clinical outcomes. Many of the interventions designed to improve adherence in chronic conditions were complex, that is, they had multiple components and were not very effective, so that the full benefit of a treatment was not realised. Nieuwlaat et al (2014) noted that frequent communication with the patient is required for the duration of the treatment to improve adherence, in which the district nursing team can play their part.
The range of adherence aids are set out in Table 2. The use of multi-compartment pillboxes (multi-compartment compliance aids (MCA)) is popular, and they include a range of devices for re-packaging medicines in individual compartments, with some including monitored dosage systems (MDS). Shenoy et al (2020) reported that the use of MCAs has almost doubled over the last decade, despite the Royal Pharmaceutical Society (RPS) (2013) presenting evidence that MCAs are not an intervention suitable for all patients and that their benefits and disbenefits should be carefully considered prior to their introduction. In particular, they may reduce patient choice (Shenoy et al, 2020) and have been associated with increased adverse events, such as drug interactions and inappropriate medication use (Chaplin, 2017).
Table 2. Adherence aids
| Reminders |
|
| Therapeutic changes |
|
An important starting point is understanding a patient's perspective and exploring their view of medicines and why they may not want or be able to use their medicines; this might include concerns, perceptions of necessity and benefits. It forms part of helping a patient to make informed decisions about their health and potential treatments, so that they can use appropriately prescribed medicines to best effect. The health professional should adapt their consultation style to include the use of appropriate communication aids so that the patient can participate as fully as they wish in the decision-making (NICE, 2009). Perversely increased patient involvement in decision-making may mean that the patient decides not to take the medicine or to cease taking a medicine despite the likely adverse effect of non-adherence on their health. The patient has the right to make this decision, as long as they have mental capacity, and should not be judged for taking a different decision from that advocated by the health professional (NICE, 2009). Adherence should be routinely assessed alongside the patient's understanding and concerns about a medicine, as these may change over time, reflecting changes in perceptual and practical barriers that can be addressed through specific personalised interventions.
Medicines are the most common healthcare intervention and, where people have more health conditions, they are likely to be prescribed more medicines. As people age, they develop more health conditions, with many older people taking multiple medicines, known as polypharmacy. Importantly, adherence becomes more problematic when people are taking more medicines, so medicine optimisation is key to ensuring that people gain the maximum benefit from their medicines (NICE, 2015). To this end, shared decision-making is advocated, taking into account a person's views regarding needs, preferences and values, so that all prescribed medicine can be taken effectively and safely to maximise health gain and minimise medication-related problems (NICE, 2015). The importance of shared decision-making and enabling the resolution of issues within a consultation is confirmed by data from the European Social Survey involving 45 700 participants from 24 countries, which explored reasons for non-adherence to prescribed medication (Stavropoulou, 2011).
Despite the need for tested interventions to inform clinical practice, Patton et al's (2017) systematic review only identified five RCTs that tested the effectiveness of interventions intended to improve medication adherence in older adults prescribed polypharmacy, four of which were pilot studies underpinned, to some extent, by a relevant psychological theory. They were unable to conclude which, if any psychological theory (social cognitive theory, health belief model, transtheoretical model, self-regulation model), was most helpful in formulating an effective intervention and recommended more research testing adherence interventions with a robust theoretical basis.
The importance of clinical interactions should not be underestimated (Box 1). Henry et al's (2012) systematic review and meta-analysis of 26 observational studies reporting non-verbal communication data found that practitioner warmth, practitioner listening and nurses exhibiting a positive personal manner were all associated with higher patient satisfaction and, in some cases, higher adherence where the data were collected. Linn et al (2016) found that satisfaction with the information and the extent to which information was personally tailored were positively related to patients' beliefs about their medication, with medication beliefs mediating the relationship between satisfaction and adherence. Thus, they argued that high-quality information as rated by the patient, which was provided by nurses in this study, can help patients to overcome their concerns and recognise the necessity and benefits of their prescribed medication.
Box 1.Effective medication-related consultation behaviours
- Active listening involves understanding what has been said and the emotions that the patient is conveying
- Positive body language comprising a relaxed and open posture and maintaining eye contact, which indicates that the nurse is focused on what their client is saying
- Open questions encourage the volunteering of information, especially relating to treatment beliefs. Closed questions are more useful when trying to identify the specifics of a problem
- The nurse should ask if the client is missing doses and establish reasons, being sure to be non-judgmental
- The nurse should summarise regularly what has been discussed, to demonstrate their understanding
- Affirmations to acknowledge the client's strengths should be used, without giving false praise, e.g. ‘even with all the problems you've had, you keep trying, which takes a lot of effort’
- Nurses should show empathy when the client is describing their experience of their chronic illness or side-effects of their medication
- To understand the client's perspective, nurses should consider using an importance ruler to assess how important adherence is to the client, where 10 is very important and 0 not at all important
- If opportunities to provide information are identified, the client's consent should be sought, e.g. ‘would you like to learn more about … ?’
- A management plan should be designed or agreed with the client, and they should be given advice on how and when to take the medication, as appropriate
- If progress towards an agreed goal is measurable, the SMART approach (specific, measurable, attainable, realistic and timed) should be considered, to aid achievement and inform follow-up discussions
- It should be explained to the client what to do if there are difficulties with the agreed management plan and whom to contact
- Time should be left for the client to ask further questions
Adapted from Abdel-Tawab et al (2011)
Abdel-Tawab et al (2011) developed and tested the Medication-Related Consultation Framework (MRCF) to evaluate the skills of practitioners undertaking medication-related consultations. The key components of effective medication-related consultations were initially identified through a literature search and then refined to become 46 consultation behaviours within five sections to form the MRCF. In testing, the MRCF has shown good psychometric properties and can discriminate between good, satisfactory and poor consultations, with its focus on content and process skills essential to delivering comprehensive, patient-centred consultations. Abdel-Tawab et al (2011) recommended the tool's use for formative assessment of medication-related consultation skills, so that practitioners can identify their strengths and weaknesses. It may also be used as a reflective tool in individual professional development for non-medical prescribers, such as nurses.
Conclusion
The COVID-19 pandemic has given added impetus to addressing the issue of non-adherence, both to reduce costs and demands upon the NHS and to support people to self-manage their long-term conditions as effectively as possible to maximise their own health gain and quality of life. Most district nursing clients will be taking more than four medicines with different regimens over a long period of time. Therefore, it is likely that there will be some non-adherence. As the health professional visiting the home, the district nurse is well-placed to understand the client perspective regarding their medicines and to promote medication adherence through the use of adherence aids in the home and high-quality clinical interactions with the client and their carer where appropriate. The district nurse is also well-placed to inform the prescriber, if they themselves are not the prescriber, about their client's adherence, so that the treatment regimen reflects the client's wishes accurately and, where the client consents, tailored supportive interventions may be offered.
KEY POINTS
- Non-adherence to medication is common, especially for treatments lasting more than 6 months
- Non-adherence may be intentional or non-intentional
- When attempting to understand the causes of non-adherence, it is important to understand the patient's perspective
- Clinical interactions can improve medication adherence
CPD REFLECTIVE QUESTIONS
- How many of your clients are prescribed more than five medicines?
- Write a reflection of how you discussed medicines with a client?
- How might you strengthen your practice to help improve adherence levels in your caseload?