Introduction

It is now clear that adherence is an issue that must be addressed by health professionals concerned to improve both the quality of life and the health outcomes of their patients or clients.

International literature suggests that 50% of people who suffer from chronic disease do not adhere to their treatment regimen and therefore do not derive optimum benefits (Royal Pharmaceutical Society 1997). A telling fact is that 50% of patients leave their GP's office without even knowing what they have been told to do (DiMatteo 1994).

Adherence to prescribed therapy has been identified as a major factor in successful asthma management (Rand 1997). However, in spite of the significant advances in developing asthma medications and the introduction of Asthma Management Plans, it appears that many people with asthma are unable to manage their therapy to best effect.

In developing this practical guide the National Asthma Council (NAC) aims to assist those involved in asthma care to understand more about adherence and the factors affecting it, both as a patient issue and an asthma management issue. It has been written to complement the Asthma Management Handbook.

Health professionals need to gain a complete understanding of adherence and the multitude of factors that contribute to poor adherence, in order to be able to assess levels of adherence and implement strategies to improve patient self-management and health outcomes.

 Structure of this guide

Section I explores the question, 'what do we mean by adherence?' This gives a broad overview of the many factors influencing adherence and presents adherence as a dynamic and complex process, which goes far beyond the correct use of prescribed medication.

Section II is largely evidence-based, and uses the international literature to identify the major influences on adherence.

Section III explores ways in which health professionals can act to improve adherence, and suggests some strategies for dealing with patients. Practical suggestions for improving adherence can be found. A set of frequently asked questions and answers is also included. Finally, we have included tools such as a questionnaire and behaviour change protocol to assist you in assessing and addressing the issue of adherence.

 

Asthma at a glance

• Over two million Australians have asthma, including:
     • one in four primary school children
     • one in seven teenagers
     • one in ten adults
   
• Asthma currently costs the Australian community between $585 and $720 million annually.
   
• Asthma is one of the ten most common reasons for seeing a general practitioner.
   

Approach of this guide

The intent of this guide is to help members of the asthma care team - doctors, pharmacists, nurses, asthma educators - to better understand issues relating to adherence and to provide some practical suggestions for modifying your practices to assist patients to improve adherence to their management regimen.

We take an evidence-based approach, drawing broadly on the published literature to understand the nature of the problem and to identify and work towards some of the possible solutions.

This guide is based on the belief that the health professional has a vital role to play in improving asthma adherence, and that a new approach to relationships with patients needs to be fostered if we are to successfully combat non-adherence.

In a recent research study, the doctor/patient relationship was cited as an important predictor of adherence (Toelle, Peat & Dunn 1998). The two most important elements of this relationship are communication and partnership . Adopting a more interactive, non-judgmental and patient-centred approach will help to establish a more open relationship with your patient. Good communication is vital in order to make a proper assessment of a patient's capacity or willingness to adhere to treatment, and to identify possible barriers to adherence.
 

As we will explore in this guide, adherence is influenced by many factors:

• the patient's attitude towards their asthma
• the priority of health in their life
• their health beliefs
• prior experiences
• complexity of life at time of consultation
• understanding of the disease
• self-efficacy

It is not possible to elicit this information from your patient when working within a strictly medical model, or acting in the role of educator or instructor. Adopting a partnership approach allows you to blend the ideal management plan with the patient's perspective, situation and goals.

A patient's motivation, beliefs and capacities in relation to medicine-taking or self-management are major influences on adherence. However, just as important is the health professional's identification and recognition of the importance of these influences. Partnership and communication are vital in any successful intervention.
 

 

Terminology

The terminology used in asthma management is more than a collection of useful words that has currency amongst health professionals. In the case of this guide it says something about the relationship between the health professional, the patient and the treatment or management regimen.
The evolution of the role of the health professional in asthma management from instructor to partner can be seen in the changing terminology:
 

 
 

Compliance implies that the patient will follow doctor's orders, is in a less informed position and has little or no input into their management strategy.

Adherence focuses more on commitment to the regimen where the therapy is the controlling factor. There is at least reasonable negotiation between members of the asthma care team and the person with asthma.

Concordance is based on a notion of equality and respect for the patient and their autonomy, the desired relationship in a therapeutic alliance between the care team and person with asthma.

We have chosen to use the term adherence in this guide. While recognising that it falls short of the desirable relationship implicit in concordance, it is the term most commonly used in the current literature drawn on for this guide, and a term with which most practitioners are comfortable.

With its focus on redefining relationships, suggesting strategies for more open communication, collaboration and partnerships, this guide promotes the spirit of concordance. The key intention of this guide is not simply to achieve better compliance with medications, or improved adherence to management plans, although of course these are vitally important. The aim is to educate and encourage health professionals to take part in concordant partnerships, so that treatment and management of asthma is informed by scientific evidence, as well as being consonant with patients' perceptions and wishes. The ultimate goal is to improve patients' quality of life and health outcomes.