Up to 50% of patients with chronic conditions do not take their medications as prescribed, contributing to at least 100,000 preventable deaths and $100 billion in preventable healthcare costs each year. Hidden hurdles to medication adherence include:
- socioeconomic challenges such as access to care and high medication costs
- condition-related factors such as lack of knowledge about conditions
- therapy-related issues such as complexity of regimens, adverse effects, and lack of medication knowledge
- patient-related concerns such as fears, beliefs, motivation, and cognition
- healthcare and system barriers including suboptimal patient and provider communication and lack of trust.
Though the contributors are commonly recognized and addressed, medication adherence remains challenging. The reasons are complex and often require a multifaceted approach.
As a pharmacist, I often encounter barriers with patients, such as those mentioned in the first three bullets, which are closely tied to the psychological, behavioral, and communication challenges described in bullets four and five. It is imperative to prioritize the latter contributing factors before addressing other concerns. For example, cost, complexity, and medication intolerability may remain hidden unless the patient feels they have enough trust in their providers to share without fear of embarrassment or directives. Though these fears may be unfounded, hesitation to share concerns may diminish as patients have more positive experiences when revealing these issues.
Tips for Ensuring Medication Adherence in Patients
Proactively asking about potential barriers to medication adherence at each encounter creates an opportunity for patients to share any challenges. Normalizing these barriers or concerns and expressing a nonjudgmental tone may help elicit genuine responses from patients. Further, when patients perceive their cultural needs, beliefs, and preferences will be heard and valued, they may be more likely to forthcoming and motivated to adhere to a treatment plan.
Example prompts I have found useful include:
“It is common for some medications to have high copays. What concerns do you have about being able to pay for your medications?”
“Many medications are well-tolerated, and occasionally some people will experience side effects, many of which are reversible and have solutions. What concerns about side effects or possible side effects do you have?”
“Before we/your provider discuss/es treatment options, what should we keep in mind that is important to you?”
Additional strategies I have found effective that honor patient voice and are getting traction in medication adherence literature include motivational interviewing and shared decision-making.
Motivational theory posits that individuals are more successful when the motivation is internally driven by self (intrinsic motivation) versus externally directed (extrinsic motivation – motivated by an outcome such as rewards or negative outcomes such as adverse health consequences. According to Self-Determination Theory, psychological needs of competence (self-efficacy – i.e. I have the ability to do this), autonomy (I have some power and choice in this situation), and relatedness (I have a sense of belonging here, I am respected) promote intrinsic motivation and are supported by strategies such as motivational interviewing and shared decision-making.
Motivational Interviewing (MI): Encourages behavior change through a patient-centered approach using empathic listening to uncover and acknowledge patients’ beliefs, preferences, barriers, and self-efficacy. MI encompasses numerous strategies, many of which build upon each other.
Shared Decision-Making Model: Facilitates exploring and respecting “what matters most” to patients and supporting them in development informed preferences. There are different approaches to shared decision-making. One example I have found useful is to ask for permission to share and then introduce choices, describe options, and help patients explore their preferences so they can make decisions about their health. Some example prompts include:
- “May I share some information with you about…?”
- “Here are the options…” “What are your thoughts about these options based on what is important to you?”
Empathetic listening, questioning, and honoring patient voices in decision-making can help uncover hidden barriers and bring awareness to patient preferences and beliefs to improve adherence to treatment plans. Some questions may feel uncomfortable at first. Find a way to make them your own. The only wrong question is the one not asked.
The CHESS Pharmacy Team can assist with overcoming hidden hurdles to medication adherence, including medication education, cost and access barriers, and solutions to reduce complexity and medication intolerances. Contact us today!
About the Author
