Adherence to Behavioral and Medical Regimens

Tricia A. Miller1,2, Summer L. Williams3, and M. Robin DiMatteo2

1Santa Barbara Cottage Hospital, Santa Barbara, CA, USA

2Department of Psychology, University of California Riverside, Riverside, CA, USA

3Department of Psychology, Westfield State University, Westfield, MA, USA

Introduction

Patient adherence (also called compliance) involves the degree to which patients follow treatment recommendations as directed by their healthcare provider. Although empirical evidence demonstrates that quality health outcomes depend heavily upon patients' adherence to recommended treatments, 25% of patients, on average, are nonadherent to prevention and disease management activities (DiMatteo, 2004). These activities include taking medications as prescribed, keeping medical appointments, engaging in regular disease screening, and following specific diet and exercise regimens (DiMatteo, Haskard‐Zolnierek, & Martin, 2012; Martin, Williams, Haskard, & DiMatteo, 2005). For patients with chronic disease, adherence can be as low as 50% or less (Vermeire, Hearnshaw, Royen, & Denekens, 2001).

Patient nonadherence can be intentional or unintentional. “Unintentional nonadherence” describes situations in which patients incorrectly believe they are adherent, or try to be adherent but fail, whereas “intentional nonadherence” describes the purposeful choice to dismiss treatment or change the regimen without consulting the provider (Lehane & McCarthy, 2007). Whether purposeful or accidental, nonadherence contributes to suboptimal health outcomes. Research has identified some clinical factors that may influence patient nonadherence, such as the complexity of the regimen prescribed, and patients' existing beliefs about the recommended treatment and the severity or seriousness of the disease condition (DiMatteo, Haskard, & Williams, 2007).

Patient nonadherence also places an appreciable economic burden on the US healthcare system. Empirical evidence suggests that as many as $100 billion dollars are wasted annually due to the cost of preventable hospitalizations (Cutler & Everett, 2010). Failure to properly adhere to treatment can also cause unnecessary complications or disease progression, with significant increases in the cost of care (Dunbar‐Jacob, Schlenk, & McCall, 2012).

Current research suggests that improving adherence requires patients' knowledge and understanding of their disease and treatment regimen, a collaborative and trusting therapeutic partnership between patients and health professionals, and satisfaction with care.

The purpose of this chapter is to highlight the importance of patient adherence, discuss several factors that affect treatment adherence, and examine the Information–Motivation–Strategy Model (IMS Model) as a way in which clinicians and healthcare professionals can improve their patient's adherence behaviors.

Factors that Affect Patient Adherence

Several factors influence whether or not patients engage in disease management and adherence behaviors. Decades of research have identified both real and perceived doubts about the expected benefits and efficacy of treatment, potential financial constraints, and the lack of resources as factors that significantly affect treatment adherence (DiMatteo, Giordani, Lepper, & Croghan, 2002; Zolnierek & DiMatteo, 2009). Socioeconomic factors, financial constraints (e.g., cost of medications), and patient characteristics can also negatively affect adherence (Peltzer & Pengpid, 2013).

Some of the unique demands of patients' prescribed treatment regimens have been associated with lower rates of adherence. These include the number of medications prescribed, the frequency of dosing, and the specific routines of administering medications for complex treatments. Patient nonadherence can be has high as 70% for treatment regimens that are complex and/or require complex lifestyle changes (Chesney, 2003). Dezii, Kawabata, and Tran (2002) found that for patients with type 2 diabetes, adherence was higher for patients on a one‐medication‐per‐day regimen compared with patients who were on a three‐medication‐per‐day regimen. Forgetting to take (or how to take) prescribed medications also contributes to patient nonadherence. Over 56% of patients forget details of their medical instructions shortly after leaving their physician's or healthcare provider's office (Martin et al., 2005). Thus, it is important that healthcare providers explain specific steps of their patient's treatment regimens, review the most important details of their patient's treatment, and use written instructions to encourage patients to ask questions and recall important information.

Patients' level of health literacy can also affect treatment adherence (Gazmararian, Williams, Peel, & Baker, 2003; Zaghloul & Goodfield, 2004). Health literacy is defined as a patient's ability to appropriately obtain, process, and understand basic health information needed to make health decisions (Baker, 2006; Schillinger et al., 2003). The Institute of Medicine (2004) estimates that more than 90 million people in the United States lack the necessary health literacy skills needed to understand and act on health information given by their providers. Patients with low health literacy often use fewer preventive services, incur higher medical costs, have more limited understanding of their treatment regimen, and have poorer health status than those with higher health literacy (Gazmararian et al., 2003; Schillinger et al., 2003; Schillinger, Bindman, Wang, Stewart, & Piette, 2004). Thus, low health literacy increases health disparities and negatively impacts patients' self‐management and collaborative care (Schillinger et al., 2004). The interpersonal dynamics of the clinician–patient relationship can also influence patterns of adherence behaviors. For example, patients who feel that their physicians communicate well with them and actively encourage them to be involved in their own care are more motivated to adhere (O'Malley, Forrest, & Mandelblatt, 2002). Such agreement fosters a cohesive partnership and allows physicians and patients to work together toward a mutually agreed upon treatment plan (Jahng, Martin, Golin, & DiMatteo, 2005). Training physicians to be better communicators results in significant improvements in patient adherence. Research by Zolnierek and DiMatteo (2009) found that the odds of patient adherence were 1.62 times higher for physicians who were trained in communication skills compared with the physicians who did not receive communication training. Effective communication also gives patients the ability to build rapport and trust; clinicians who promote trust through collaborative partnerships and who express compassion and “bedside manner” for their patients are more likely to succeed in fostering adherence and cooperation for a variety of treatment regimens (Schillinger et al., 2003).

Improving Adherence Using the Information–Motivation–Strategy (IMS) Model

Current empirical research highlights the complexity of establishing adherence‐enhancing interventions and suggests that interventions should be tailored to meet the specific needs of patients for the most optimal effectiveness (DiMatteo et al., 2012; Martin et al., 2005). Evaluating and targeting patients' specific needs can be a difficult task for clinicians and healthcare providers, however, especially given the limited time constraints of the medical visit itself.

A well‐organized and simple model known as the Information–Motivation–Strategy Model(c) can be used by clinicians and healthcare teams during medical encounters to help guide and promote patients' adherence behaviors (DiMatteo et al., 2012). Utilizing these three elements, that is, providing patients with information, building motivation, and offering effective strategies, in the context of effective clinician–patient communication can result in substantial and significant improvements in adherence and overall health outcomes.

The information element of the IMS Model outlines the importance of empowering patients to become more knowledgeable about their disease or condition by means of effective clinician–patient communication. In a review assessing more than 300 studies, researchers found that patients often do not understand much of the information they receive from their healthcare provider (Kindig, Panzer, & Nielsen‐Bohlman, 2004). Proper understanding can be achieved when clinicians communicate effectively with their patients, however (Zolnierek & DiMatteo, 2009). Empirical research suggests a 19% higher risk of nonadherence among patients whose physician communicated poorly than among patients whose physician communicated well (Zolnierek & DiMatteo, 2009). Thus, cohesive partnerships, in which clinicians work together with their patients, make it possible for clinicians to both effectively and thoroughly provide clear information and check the adequacy of their patients' understanding (DiMatteo et al., 2012). Patients who feel that their clinicians communicate well with them and encourage them to be involved in their own care tend to be more motivated to adhere (Martin et al., 2005).

A patients' level of trust in their physician is also an essential component of the physician–patient relationship and can greatly affect patient adherence. Patients must believe that their physician is someone who can understand their unique experience and who can provide them with reliable and honest advice. Martin et al. (2005) found that adherence rates were almost three times higher in primary care relationships consisting of higher levels of patient trust and physicians' knowledge of their patient as a person. In fact, patients' trust in their physician has been found to exceed many other variables in promoting both patient adherence and overall satisfaction with care (Martin et al., 2005).

The second element of the IMS Model, motivation, emphasizes the importance of shared decision making between patients and their physician in order to develop a treatment plan the patient believes in and one to which the patient can make a commitment (DiMatteo et al., 2012; Zolnierek & DiMatteo, 2009). Helping patients to believe in the potential efficacy of a recommended treatment and the establishment of informed collaborative choice can influence a patients' motivation to adhere (Zolnierek & DiMatteo, 2009). Some research suggests that when a patient believes in the importance of their recommended treatment, healthcare teams can use behavioral contracts to gain further commitment (Martin et al., 2005). Ultimately, patients are more adherent to treatment if they believe that the consequences of nonadherence are more detrimental to their health than if they take the consequences of nonadherence less seriously. Thus, it is extremely important for health professionals to discuss openly, with their patients, any beliefs and specific perceptions or expectations of treatment that may hinder adherence behaviors.

The final element of the IMS Model involves developing workable strategies or resources to help patients overcome any (real or perceived) barriers that may hinder adherence. Members of the healthcare team must be willing to direct patients to resources to overcome such barriers as the financial cost of medication, the disadvantages of complex treatment regimen, or the lack of transportation to scheduled appointments. Patients also need assistance and encouragement to access supportive resources from their social support group (such as spouse, family, or friends) and any other aid that might be available to them to support the regimen (e.g., community‐ or work‐based interventions) (Miller & DiMatteo, 2013). Health professionals should routinely assess the levels of social support available to their patients, as research by DiMatteo (2004) has shown that the absence of social support is a significant barrier to adherence.

The IMS Model can be used as simple heuristic through which clinicians can target the specific needs of their patients in order to establish the most effective treatment. The IMS Model illustrates that knowledge, commitment, and ability are essential for improving patient adherence (DiMatteo et al., 2012).

Conclusion

Patient adherence is essential for the achievement of quality healthcare outcomes. Effective patient communication can increase patient satisfaction, improve overall quality of life, and ultimately reduce the risk of nonadherence. Current empirical research continues to try to understand, assess, and predict the many challenges that patients face in the management of their care. The elements of the Information–Motivation–Strategy (IMS) model can be used by clinicians and health professionals to assist patients in building effective long‐term disease management strategies to improve overall health outcomes and ultimately maximize adherence to treatment.

Author Biographies

Tricia A. Miller, PhD, is the research scientist for Cottage Children's Medical Center. She received her doctorate from the University of California, Riverside, in social‐personality psychology. Her research focuses on the social psychological process of health and medical care delivery including provider–patient communication and treatment adherence. Dr. Miller is a lead contributor to grant‐funded projects examining Pediatric Care Coordination among medically complex children and improvements in clinical and social outcomes for very low birth weight infants and their families.

Summer L. Williams, PhD, received her doctorate in social‐personality psychology from the University of California, Riverside. Her research expertise is in health communication and health outcomes research, where she has spent the last decade examining doctor–patient communication in diverse populations, patient adherence, and patient satisfaction. She is an associate professor at Westfield State University in Massachusetts, currently teaching courses in introductory psychology, health psychology, social psychology, psychology of illness, and health of vulnerable populations.

M. Robin DiMatteo, PhD, is a distinguished professor emeritus of psychology at the University of California, Riverside. She received her BS in mathematics and psychology from Tufts University, and her MA and PhD degrees from Harvard University. She has served as a resident consultant in health policy at the RAND Corporation. Dr. DiMatteo has been elected Fellow of the American Association for the Advancement of Science. Dr. DiMatteo received the Distinguished Teaching Award from the University of California, Riverside, and is a member of the UCR Academy of Distinguished Teachers.

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Suggested Reading

  1. Riekert, K. A., Ockene, J. K., & Pbert, L. (Eds.) (2014). Handbook of health behavior change (4th ed.). New York: Springer.