Adherence is best with the lowest number of medications and the lowest dosage intervals. Improve patient recall by providing written education material and a written record of medication names and doses. Encourage correct usage by checking aerosol technique. Positively reinforce specific efforts to improve adherence. Identify health beliefs around asthma and medication. Elicit family support.
What are some strategies to improve my adherence?
Your doctor can suggest strategies, and they should relate to the underlying problem that is preventing you from taking drugs. If side effects are the problem, your doctor may be able to suggest ways to manage your side effects better. Many side effects are time limited, and will improve over the course of therapy.
Some people find taking pills depressing and upsetting, because it reminds them too much of their illness. It may be helpful to get counselling if you feel this way, or if you have other HIV-related issues.
Sometimes it's not easy to find enough privacy to take medications. Your doctor may be able to switch you to an alternate dosing schedule, or suggest times when it may be easier to take your meds.
If you have problems remembering when or how to take medications, a doctor or pharmacist may be able to give you some practical tools. Examples include personalized medication schedulers, "dosettes" (pill boxes with compartments to arrange all your doses for the day or week), or timers that can be programmed to alert you when to take your drugs.
It's also important to understand why adherence is so important. You may be more willing to "be adherent" if you understand why that will help you, instead of feeling like you're simply following orders.
A commitment to partnership and a more equal relationship with your patient will foster communication and encourage the patient to take control of their self-management. This attitude should be based on a desire to understand the patient, their beliefs, their attitudes, their daily situation and schedule, and a non-judgmental attitude towards their non-adherence.
Focusing on the positive benefits of adherence, rather than the negative consequences of poor adherence, and devising practical strategies to address the impositions of treatment on the patient's life, will help to achieve a positive outcome. It is important to communicate to the patient that adherence will give them control, rather than asthma controlling them. If strategies or treatments have an unsatisfactory result, encourage the patient not to see it as a failure. Adverse reactions discourage adherence. Your attitude will help the patient to regard such incidents as learning experiences, rather than evidence that it's all too hard.
Asthma educators are increasingly becoming valuable members of the asthma care team. Education is crucial to adherence, as well as to asthma management in general. More and more GPs are referring patients to asthma educators, who have the time and specific knowledge and skills to ensure patients understand their condition and their treatment.
Develop open, communicative, non-judgmental
relationships with patients
• Normalise poor adherence in dealings with your
patient
• Adopt a partnership approach to asthma
management with your patient
• Involve your patient in the planning process
• Simplify treatment where possible, and strive to
tailor treatment plans to your patient's
preferences, needs and capabilities
• Ensure that your patient understands their
asthma and treatment
• Collaborate with other health professionals to
improve patient outcomes
• Aim to build a partnership with patients for
ongoing care
• Encourage regular reviews and ongoing
monitoring of adherence levels
• Develop systems (such as reminders) to prompt
patients on long-term treatment programs.
• Use appropriate information-gathering skills
It is possible to facilitate better communication with your patients by:
• using skills such as open-ended questions at
the beginning of the consultation
• avoiding questions that elicit a yes/no
response or that are judgmental in their tone
• showing empathy and warmth and following
up on the patient's verbal clues.
Such communication strategies will make it easier to assess possible non-adherence, and make it easier for the patient to discuss their individual issues and barriers to good adherence.
• Facilitate open discussions with your patient
about adherence
Your attitude and your manner will help your patient to be honest and realistic when you are discussing adherence to different treatments for asthma. It is important to be non-judgmental and to normalise poor adherence (remember, around 50% of patients don't adhere to prescribed therapy).
Ask questions that will elicit information about the patient's health beliefs, their attitude to their diagnosis and their willingness to make behaviour changes in order to better manage their asthma .
• Use reminders
A number of prompts and reminders have been demonstrated to improve adherence:
- telephone or postcard reminders
- individualised reminder charts
- diaries
- engaging family members and carers to provide reminders
• Facilitate recall
Health practitioners who use strategies such as repetition, giving specific advice, using written information, increase the recall of the patient. Knowledge of what to do is a prerequisite of adherence (Royal Pharmaceutical Society 1997).
Improve patient recall by providing written education material and a written record of medication names and doses.
• Explain likely side-effects
One of the quickest ways to engender non-compliance with therapy is for a patient to experience side-effects about which they have not been forewarned. Discuss possible side-effects and suggest ways these can be minimised.
Always provide an opportunity for patients to express any concerns about the medication. Unvoiced concerns about continued drug use are a prime reason for discontinuing appropriate self-management. Give a balanced explanation of the benefits/risks of the medications.
• Involve the patient in the planning process
One way to encourage regular review is to focus on short-term goals while highlighting the long-term objectives. Short-term goals set around patient priorities such as sporting participation or fewer days off school or work are more likely to be successful than physiological goals such as peak flow. Setting end points, where patients know that reaching a certain goal will result in changes to medication, may encourage regular review (Sawyer 1998).
• With older patients, remember that the number of medications prescribed increases with age. The more medications used, the less likely people are to adhere. As the numbers of medications prescribed increases with age, the elderly are particularly at risk (Australian Institute of Health and Welfare 1994). If possible, not more than 3-4 drugs should be given each day.
• Explain to the patient (or their parent/carer) that you are trying to make them more competent to manage the disease themselves - and that your role is as an adviser.
• Don't try to instruct patients in all aspects of asthma at one consultation - build their knowledge base over consecutive visits.
- In the Sharma et al study questionnaire was designed specifically for the study, and using the questionnaire the results will be obtained. Questionnaire was used to assess people’s attitudes towards eating particular foodstuffs over the preceding three days. Using a questionnaire has advantages and disadvantages, first of all a questionnaire is fairly easy to organize and collect vast amounts of data, aswell as taking relatively small amount of time to carry out . Questionnaires are also a cheap way of gathering data, also large amounts of subjects can be used. However on the down side, it doesn’t allow for the gathering of detailed responses. If open ended questions such as, ‘what methods would you like to see in order to lose weight?’ were asked subjects would have the chance to express themselves and therefore make the study more valid.
Another evaluation issue that can be taken into account is generalisation. Sethi et al argues that there is a relationship between adherence and drug resistance. The results show that there is a significant positive correlation with resistance to the HAART drugs. However are we able to assume that this also applies to other medical conditions or treatment regimens? Different drugs have different effects on different people, thus limiting our ability to generalize.
Ethnocentricity is an issue that can be questioned in the Sharma et al study since this investigation took place in America; could it be generalized to people in the non-western world, the LEDC’s? The results are appropriate for America as a minority live below the poverty line, and thus for majority consumption of food is not the problem, however the results can’t be applied to the rest of the world because people especially in the Third World countries, have different level of food consumption i.e the daily calorie intake is much below that of America or any other western country.
BPS ethical guidelines should be cohered with when conducting research into adherence. Yung ensured that all participants with non-insulin dependant diabetes mellitus gave informed consent; therefore this study did meet the BPS guidelines in informing participants of the objectives of the research. Watt et al didn’t gain consent from the children themselves, those that would be using the ‘Funhaler ’ due to the reason that they were under 16 years of age, and thus consent was gained from their parents.
Sethi et al has face validaty as the researchers asked the patients how many doeses of medication they had missed over the previous three days and their response
