Section I - What we mean by Adherence

Although compliance with the prescribed therapy is the cornerstone of effective asthma management, we need to keep in mind that adherence is a much more complex and broad concept than correct use of medication. This section attempts to widen the definition of adherence and identify the multitude of issues associated with the concept.

The Nature of Adherence

Adherence needs to be redefined from being a static concept to a dynamic process (Campbell 1997). Adherence is never static, and is affected by such factors as the different medications prescribed, the duration of treatment, the length of time between visits to the doctor, the patient's daily schedule, family situation, and so on.

It is a widely held belief that adherence decreases over time, and that adherence with acute medication (e.g., 10 days' treatment with antibiotics) is far more likely to be successful than medication given on a longer term, as with asthma. However, it should be noted that adherence rates can be very low even for very acute interventions.

In various different study populations, adherence with 10 days' antibiotics has been demonstrated to be as low as 5% in some patients, to around 63% in others. In one study, 56% had stopped penicillin by Day 3 and 83% stopped by Day 9 of a 10-day course (Bergman & Werner 1963).

 Adherence to What

Medication is only one aspect of adherence, particularly in the case of asthma management. As health professionals, we ask patients with asthma to adhere to a set of complex interrelated behaviours, including:

• medication compliance
• compliance with a written management plan,
• including attendance at follow-up appointments
• allergy and trigger factor avoidance strategies
• peak flow monitoring
• medication use techniques
• recording of symptoms
• regular review

Patterns of Adherence

There are several types of non-adherence, as well as degrees or levels of adherence. Researchers have developed the following categories of non-adherence:

Primary - when the patient does not get the prescription filled or fails to attend an appointment

Secondary - when the treatment is not taken as prescribed

Intentional - when the patient rejects the diagnosis or treatment

With this type of non-adherence, communication with patients is vital in order to understand their health beliefs, their feelings about their asthma and medications, and the barriers to adherence and conflicting priorities which lead patients actively to reject treatment.

Unintentional - may be due to a range of factors, but not planned, e.g. the patient would have taken the medication but they ran out, forgot it at home, stayed at a friend's house etc.

Unintentional poor adherence is the area most strongly linked to a large number of demographic, social, or clinical variables and influences, which will be discussed in Section II.

Why is Adherence a Problem

Just as there are different patterns of poor adherence, there is an even broader range of factors and influences acting on patients who don't satisfactorily adhere to treatment. The medical argument for adherence is only one influence upon patients, and it competes with personal, social, cultural and lifestyle factors which are constantly influencing the patient and their behaviour and choices in relation to managing their health. This guide will go on to look more closely at these influences on adherence in the next section.

Every patient is different in their beliefs about their health and their asthma, their daily routine, their aspirations and goals, and their capacity to adhere. The complex set of factors which influences a patient's ability or desire to adhere is also constantly shifting over time, with the patient's changing circumstances and the level of severity of their asthma. This is why health professionals need to expand their traditional roles as diagnosticians, educators, or physicians, and work on improving their skills as communicators.

At the most basic level, poor communication skills can lead to a patient not understanding what they need to do in order to adhere. The patient's language and literacy skills, their cultural background, and age all need to be kept in mind when giving advice, prescribing or dispensing medication or providing education about asthma.

Patients typically only follow recommendations they really believe in and those they actually have the ability to carry out (DiMatteo 1994). Sometimes patients need practical help to develop the necessary skills to remember to take their medication, or to avoid their trigger factors. The more complex the treatment regimen, the easier it is for the patient to make a mistake and unintentionally not adhere. Factors such as the patient's age, daily schedule, and number of other medications being taken for other complaints can make the task of adhering to their management plan more difficult. Later, we discuss practical strategies such as reminders and written information to help combat non-adherence.

Perhaps the most important information which can be gained from better communication is the patient's attitude to their health and their asthma. Do they think it's worthwhile to adhere at all? The consequences of poor adherence may not be seen as negative by some patients, when compared with the perceived costs of good adherence, such as reduced spontaneity, or disruption to established routines. Many people who live with severe asthma symptoms for a long time forget what good health feels like and accept a health status that, to health professionals, seems far less than optimal.

Adherence: Whose Responsibility

Adherence and self-management are the joint responsibility of the patient and members of the asthma care team. The latter have a responsibility to ensure that the patient is receiving the best possible treatment, education, and advice to facilitate a good level of adherence. Poor adherence is far more than simply the patient's fault, and it is now generally accepted that the responsibility for promoting better adherence lies with the health professional (Sawyer 1998). With positive, open and non-judgmental relationships, both health professionals and patients can keep to their part of the 'contract of care'.

The past ten years have seen a more collaborative team approach to patient care, and asthma management is no exception. General practitioners, pharmacists, asthma educators and nurses all have vital roles and responsibilities in improving patient adherence and asthma management.

How Much Adherence is Enough

The question of how much adherence is enough is difficult to answer. Of course 100% adherence is the ideal, but for most people, complete adherence is not necessary to successfully manage their asthma to a level that enables them to achieve their personal goals and chosen activities in life.

Not all drugs rely on adherence to the same extent in producing effective responses. Some regimens are more flexible than others. It is perhaps self-evident that poor adherence begins to affect clinical outcomes when it reaches 'the point below which the desired preventive or therapeutic result is unlikely to be achieved' (Gordis 1976). There is no measurable level which applies universally. Each case must be assessed on its own merits, for example, the type of medication prescribed, the lifestyle, goals, and capacities of the patient.

For each patient, you should consider what they are losing when they deviate from their treatment regimen. What are the effects of the patient's poor adherence? Are they severe enough or inconvenient enough to modify the patient's behaviour, with help from you or other health professionals? Minimum levels or basic requirements should be discussed, in consultation with your patient. A better understanding of your patient and their situation may not achieve 100% adherence, but will improve adherence along with their quality of life and health outcomes.

Benefits of Adherence

If health professionals and patients can work together to improve adherence, the benefits will be felt at all levels of society. Patients have the most to gain from improving their adherence to asthma management plans and treatment regimens. Health professionals know that use of preventive strategies leads to improved health outcomes. From the patient's point of view, proper adherence can mean a symptom-free existence, with a dramatically improved quality of life. Being able to control their asthma gives people a greater capacity to take part in their chosen activities, and achieve their goals.

The challenge for health professionals is to convey the potential benefits of improving adherence to prescribed therapy. The asthma care team will gain satisfaction from knowing they are making a real difference, and taking part in a successful therapeutic alliance that is reducing the cost of asthma to individuals and the community. There is evidence that the positive, communicative approach being advocated in this guide leads to better health outcomes, more satisfied patients and shorter consultations (Clark et al 1995).

The community will benefit by adherence in having more fully participative members of society, who are not disadvantaged or constrained by the effects of asthma symptoms. Better management of asthma results in fewer work days lost for adults, and reduced school absenteeism for children. It is believed that along with hospital admissions from asthma, half to two thirds of asthma deaths should be preventable (Bauman 1998). If we can improve adherence and continue to manage asthma more successfully, we can reduce the human cost of asthma and the costs to the health care system of emergency and hospital admissions or other crisis interventions.