What is adherence to medical advice?

Adherence to medical advice occurs when individuals follow the guidance provided by healthcare professionals, such as taking prescribed medications or attending scheduled appointments.

Non-adherence, in contrast, refers to any failure to follow this advice.

Types of non-adherence

Unintentional non-adherence

This type happens when patients intend to follow medical advice but face barriers beyond their control, preventing them from doing so.

Examples of unintentional non-adherence:

• Forgetting or not remembering - Patients may simply overlook instructions or appointments.
• Lack of understanding - Complex advice from doctors might not be fully comprehended.
• Financial barriers - The cost of treatments can make them unaffordable.
• Work or time constraints - Inability to take time off for appointments or treatments.

Intentional non-adherence

Here, patients actively choose not to follow advice, often due to personal beliefs or perceptions about the treatment.

Examples of intentional non-adherence:

• Beliefs about harms - Concerns over immediate or long-term side effects.
• Perceived benefits - Doubts about whether the treatment will help now or in the future.
• Cost and regime factors - High financial costs or inconvenient dosing schedules.

Failure to follow treatments

One common form of non-adherence involves not sticking to prescribed treatments, like medications. This can stem from either unintentional or intentional reasons, as outlined earlier. For instance, unintentional cases might involve forgetting doses, while intentional ones could arise from weighing up side effects against benefits.

Key intentional factors influencing decisions about treatments: Laba et al. (2012)

1. Immediate harms from the medication
2. Long-term harms from the medication
3. Immediate benefits of the medication
4. Long-term benefits of the medication
5. Financial cost of the medication
6. The treatment regime (e.g., how often it must be taken)

Failure to attend appointments

Another key aspect of non-adherence is missing scheduled medical appointments, which is a widespread issue causing significant waste in healthcare resources worldwide. Past missed appointments often predict future ones, creating a cycle that exacerbates the problem.

Common reasons for missing appointments

• Work or family commitments making attendance difficult
• Forgetting the appointment date or time
• Transportation challenges, such as getting to the hospital
• Believing the appointment is not needed
• Being too unwell to travel
• Fear or mistrust of hospitals
• Anxiety about discovering a serious illness

A review by Parsons et al. (2021) of 12 studies confirmed that work/family issues, forgetting, and transport problems were the most frequently cited reasons.

Groups most likely to miss appointments

• Individuals under 21 years old
• Those over 80 years old
• People from lower social classes or with low socioeconomic status
• Those who have missed appointments before
• Individuals with existing mental or physical health diagnoses
• Members of minority ethnic groups

Problems caused by non-adherence to appointments

• Failing to attend can lead to several negative outcomes, affecting both patients and the healthcare system.
• Unresolved medical issues that worsen over time
• Increased costs to the health service from wasted resources
• Delayed treatments, which may require more intensive interventions later, such as stronger medications or surgery

Explanations for non-adherence

Rational non-adherence

This explanation suggests that patients make reasoned choices not to follow advice when they believe it's not in their best interest.

According to Sarafino (2006), common rational reasons include:

• Believing the medication isn't effective
• Feeling side effects are worse than the benefits
• Confusion over dosage or timing
• Inability to afford the treatment
• Testing if the illness persists without medication

Supporting research by Bulpitt and Fletcher (1988) examined patients with high blood pressure. They found that 8% stopped medication due to sexual problems, and 15% due to tiredness, sexual issues, and gout. Patients rationally ceased when side effects outweighed benefits, illustrating how personal cost-benefit analysis drives non-adherence.

Health belief model

The health belief model explains adherence to preventative actions based on perceptions of health threats and the value of responding. It proposes that action is more likely if the problem feels serious and benefits outweigh barriers.

Key considerations in the health belief model:

Additional influences include demographic factors (e.g., age), personality traits, and social class, which can modify these perceptions.

Key research: Laba et al. (2012)

Laba et al. (2012) investigated factors influencing intentional non-adherence, focusing on how patients weigh medication options.

Aim

To examine decisions leading to intentional non-adherence and assess the importance of medication factors versus patient background.

Participants

248 Australians with a median age of 57 years; 45% male and 55% female. Of these, 161 completed an online survey.

Method and procedure

An experimental design used a discrete-choice questionnaire based on the Beliefs About Medication Questionnaire (BMQ). Participants chose between two hypothetical drugs across ten questions, evaluating factors like symptom severity, side effects, benefits, costs, and regime.

Example comparison:

Results

Six of eight factors affected choices: reducing death risk was most important, followed by current side effect severity and future risks. Side effects influenced decisions more than benefits. Those with medical insurance were less cost-sensitive.

Conclusions

Patients make rational choices about adherence. Improving adherence could involve lowering costs, simplifying regimes, and educating on benefits.

Evaluation

Issues and debates in non-adherence research

Application to everyday life

Insights into non-adherence have practical value. For example, recognising that costs and complex instructions contribute to non-adherence allows healthcare professionals to implement strategies like subsidising medications or simplifying guidelines, potentially improving patient outcomes in daily healthcare settings.

Idiographic versus nomothetic approaches

Research like Laba et al. (2012) adopts a nomothetic approach, using quantitative data and statistical analysis to draw generalisable conclusions about adherence factors across groups. This provides objective, reliable insights but limits depth, as fixed questions prevent personal explanations. An idiographic approach, incorporating open-ended questions for individual perspectives, could offer richer insights into unique motivations, complementing the broader patterns.