Defined by the World Health Organization as ‘the extent to
which a person’s behavior [in] taking medication…corresponds with agreed
recommendations from a health care provider’
– World Health Organization
Term COMPLIANCE has come into disfavor because it suggests that a person
is passively following a doctor’s orders, rather than actively collaborating in
the treatment process.
on the other hand, requires the person’s agreement to the recommendations for
is defined as the ability of a person to continue taking medications for the
intended course of therapy.
the case of chronic diseases, the appropriate course of therapy may be months, years,
or even the person’s lifetime.
person is classified as non-persistent if he or she never fills a prescription
or stops taking a prescription prematurely.
the intended course of therapy when medications are first started has been shown
to be an important factor in keeping people persistent with a medication regimen.
Adherence is a multidimensional phenomenon determined by the
interplay of five sets of factors, termed “dimensions” by the World
care system factors
1. SOCIAL AND ECONOMIC DIMENSION
English language proficiency
of family or social support network
living conditions; homelessness
access to health care facilities
of health care insurance
or difficulty accessing pharmacy
and lay beliefs about illness and
2. HEALTH CARE SYSTEM DIMENSION
communication skills (contributing
to lack of patient knowledge or understanding of the treatment regimen)
between the health beliefs of the
health care provider and those of the patient
of positive reinforcement from the health
- Weak capacity
of the system to educate patients
and provide follow-up
of knowledge on adherence and of effective
interventions for improving it
information materials written at too
high literacy level
formularies; changing medications
covered on formularies
drug costs, copayments, or both
access or missed appointments
- Long wait
of continuity of care
3. CONDITION-RELATED DIMENSION
4. THERAPY-RELATED DIMENSION
of medication regimen (number of daily
doses; number of concurrent medications)
requires mastery of certain techniques
changes in medication regimen
of immediate benefit of therapy
with social stigma attached to use
or perceived unpleasant side effects
interferes with lifestyle or requires significant behavioral changes
5. PATIENT-RELATED DIMENSION
mobility or dexterity
risk/susceptibility to disease
reason medication is needed
or attitudes toward treatment
benefit of treatment
in ability to follow treatment
of possible adverse effects
stigmatized by the disease
with health care providers
stress, anxiety, anger
or substance abuse
There are several ways to measure medication adherence.
1. Medication event monitoring
These are the most accurate method of measuring adherence because
they record the date and time the medication bottle was opened through
microprocessor technology embedded in the cap.
Advantages with microprocessor:-
faith/falls., because pt may remove
more than one dose
- Very expensive
& different devices are needed
for each medication
it is an impractical way to determine adherence in clinical practice.
self-reports is easiest method when adherence is being assessed, open-ended
questions should be asked.
Instead of asking, “Are
you taking your medications?” the HCP should phrase the question along the lines
of, “How many times in the past week (month) have you skipped your medications?”
3. Pill counts
4. Pharmacy databases
or refill rates, and
5. Blood levels which
also are employed in
research, are more feasible options for clinical practice
6. Morisky’s Medication
Adherence Scale (MMAS) It was designed to distinguish poorly adherent
patients from those with medium- to-high adherence to their antihypertensive
MMAS consists of questions addressing multiple reasons for non-adherence..
e.g., because regimen complexity can lead to noncompliance.
The scale contains a question assessing whether the patient feels
hassled (trouble/Tense) about his or her regimen
patients tend to give their HCPs positive answers to please them, the questions
in Morisky’s study were phrased to avoid this bias.
question measures a specific medication- taking behavior rather than adherence or
Methods Can Improve Medication Adherence by Pharmacists
Kitchen Table Consults
Pharmacy Work Flow
Reasons for Medication Non- adherence
Patients Specific Questions About Their
ROLE OF THE PHARMACIST
medication dispensing is the best- known function of the pharmacist,
counseling, medication therapy management (MTM), disease-state management, and
other means—can play a pivotal role in patient care.
are opportunities in every type of pharmacy practice to improve patients’ adherence
and therapeutic outcomes, and pharmacists must embrace and act on them.
1. Patient Education
2. Dosing simplification and minimization of adverse effects are extremely successful strategies for improving adherence.
3. Preparing a dosing card
containing only the most essential
elements of the patient’s medications can be highly beneficial
be extremely helpful for patients who take many medications or who have cognitive
4. Reminder calls, texts, or e-mails are helpful for
many patients, especially those with busy lifestyles. Automatic refills are a useful
the barriers to adherence may be, the only way to assess them is to talk to the
pharmacist needs to be diligent (pay attention) about including the patient in the
more trust the patient has in the pharmacist, the more he or she will open up
and disclose any apprehensions or difficulties about taking his or her
medication. Only then can the pharmacist play an integral role in improving a patient’s
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