Adherence and Communication
Summary and Keywords
Patient adherence (sometimes referred to as patient compliance) is the extent to which a patient’s health behavior corresponds with the agreed-upon recommendations of the healthcare provider. The term patient compliance is generally synonymous with adherence but suggests that the patient played a more passive role in the healthcare professional’s prescription of treatment, whereas the term adherence suggests that the patient and healthcare professional have come to an agreement on the regimen through a collaborative, shared decision-making process. Another term related to the concept of adherence is persistence (i.e., taking a medication for the recommended duration). Some patients are purposefully or intentionally nonadherent, whereas others are unintentionally nonadherent due to forgetfulness or poor understanding of the regimen. Patients may be intentionally nonadherent because of a belief that the costs of the regimen outweigh the benefits, for example. Nonadherence behaviors in medication-taking include never filling a prescription, taking too much or too little medication, or taking a medication at incorrect time intervals. Patient adherence is relevant not only in medication-taking behaviors, but also in health behaviors such as following a specific dietary regimen, maintaining an exercise program, attending follow-up appointments, getting recommended screenings or immunizations, and smoking cessation, among others.
There are a number of factors that predict patient adherence to treatment, but the relationship between provider-patient communication and adherence to treatment will be stressed here. Focusing on recent research, this article examines the concept of patient adherence, describes how provider-patient communication can enhance patient adherence, explains what elements of communication are relevant for adherence, and illustrates how interventions to improve communication can improve adherence.
Overview of Adherence: History, Measurement, and Outcomes
The terms patient adherence and patient compliance were first reported in published studies in 1966 (Davis, 1966; Wilson, 1966). In 1979, R. Brian Haynes (Haynes & Sackett, 1979) proposed the following now commonly accepted definition of adherence: “the extent to which a person’s behavior (in terms of taking medications, following diets, or executing lifestyle changes) coincides with medical advice” (pp. 1–2). Since that time, thousands of studies on the topic of adherence have been published, involving scholars from medicine, epidemiology, psychology, nursing, and public health, among other disciplines. Efforts to synthesize and systematically review the adherence literature have been undertaken by M. Robin DiMatteo, who has published multiple meta-analyses of predictors of adherence including a seminal meta-analytic review of the corpus of adherence literature (DiMatteo, 2004b). Another key author in this field is Haynes, who conducted one of the first systematic reviews of the literature on interventions to improve patient adherence (Haynes, 2008). Extensive research has also focused on interventions to improve adherence, and it is recognized that no one intervention will work to improve the adherence of all patients (Martin, Williams, Haskard, & DiMatteo, 2005).
Rates of nonadherence vary depending on disease, regimen, patient population, and other factors, but on average, rates of nonadherence range from 25% to 50% (DiMatteo, 2004b; Sabaté, 2003). Nonadherence rates tend to be higher with regimens associated with lifestyle changes, such as beginning an exercise regimen after leading a sedentary life or making major changes to one’s dietary habits. Other factors affect rates of adherence, including category of illness (i.e, acute vs. chronic) with higher rates of adherence in acute illness compared to chronic illness (DiMatteo, 2004b). Adherence rates can drop over time in many diseases. Regimen characteristics also affect rates of adherence, as patients are more adherent with simpler regimens, as demonstrated in a meta-analysis of adherence to antihypertensive medications (Iskedjian et al., 2002). Across eight studies, once daily dosing regimens were associated with higher adherence rates than twice or multiple daily dosing schedules. When a regimen is more complex and requires greater adjustment to one’s lifestyle, adherence tends to suffer. Furthermore, adverse side effects associated with a medication can predict adherence levels, as experience of troublesome side effects can cause a patient not to take medication as prescribed.
There are serious health consequences of nonadherence. When patients do not adhere to recommended treatment, they can experience poorer health outcomes, such as continuation or worsening of symptoms or progression of their disease. Specifically, a meta-analysis of 63 studies examining adherence and outcomes of treatment across diseases revealed the odds of a positive health outcome were almost three times higher if a patient was adherent to treatment (DiMatteo, Giordani, Lepper, & Croghan, 2002). A meta-analysis of the relationship between medication adherence and mortality across 21 studies demonstrated that patients with good adherence to medication had about half the risk of death of those individuals with poor adherence (Simpson et al., 2006). Examples from individual studies and in specific diseases abound. For instance, diabetes patients who are nonadherent to medication have higher HbA1c levels as well as greater risk of hospitalization and death from all causes (Ho et al., 2006). In HIV, patients who have medication adherence of 95% or more experience a host of better outcomes, including greater number of CD4 cells, reduced likelihood of virologic failure, fewer days of hospitalization, and lower risk of opportunistic infections or death (Paterson et al., 2000).
In addition to the health outcomes of nonadherence, there are financial ramifications, including unused prescriptions, wasted time in medical visits, and unnecessary hospitalizations; some estimates of these costs due to nonadherence have been as high as $300 billion per year (DiMatteo, 2004b). Nonadherence also affects healthcare providers, whose ultimate goal is to help their patients heal and achieve better health. When patients are nonadherent, a trusting relationship between a patient and his or her healthcare provider may suffer, as providers are frustrated and challenged.
Healthcare professionals frequently underestimate patient adherence; thus, it is particularly important to measure adherence accurately. Measurement methods are often categorized into either direct or indirect methods, and there is unfortunately no “gold standard” measure of adherence, as all measures have both advantages and drawbacks (Osterberg & Blaschke, 2005). Direct measures include directly observing the patient taking medication and measurement of levels of medicine or metabolite in blood. Direct observation is difficult in everyday practice, and physiological measures are invasive. Indirect methods include self-report, pill count, pharmacy refill records, and electronic monitoring. The most frequently used and affordable method of measurement is self-report, although bias is possible with this form of measurement. With pill counts, patients can dispose of pills before they are counted, and pharmacy refill records do not indicate whether a patient has actually ingested a medication. Electronic monitoring involving automatic indicators of the time and date pill bottles were opened can be quite accurate but also quite expensive. Ultimately, the use of multiple measures of adherence is recommended to current researchers in the field to improve accuracy.
Predictors of Adherence
One challenge in understanding and intervening to promote patient adherence is the myriad factors that predict adherence behavior, which differ from patient to patient. Researchers have organized the predictors of adherence into three main categories: patient-related factors, provider-patient interaction factors, and healthcare system factors (Osterberg & Blaschke, 2005). Demographic characteristics or patient personality traits have not been shown to be consistently predictive of adherence. Patient-related factors that are predictive of adherence include mental health (i.e., depressed patients have greater levels of nonadherence to treatment Grenard et al., 2011) and social support (i.e., patients with lower levels of social support, including a more distant family, are less adherent to treatment DiMatteo, 2004a). Other patient factors related to adherence are beliefs and attitudes; when a patient does not believe in the efficacy of the regimen or believes the risks outweigh the benefits, his or her adherence is lower (Wong, 2009). Patient cognitive factors are also related to adherence. For example, a common barrier to adherence for patients is forgetfulness, as patients struggle to remember to consistently take their medication. Also if patients do not understand how to take a medication or related requirements, such as substances they must avoid while taking the medication, they may be more likely to be nonadherent.
Healthcare system factors related to adherence include costs of medications, access to medical care, and insurance status. For example, if access to appointments is poor, patients may struggle to attend required follow-up appointments. Patients who face significant out-of-pocket costs for their medication may take less medication or not fill their prescriptions on schedule because of the financial barriers.
Finally, provider-related factors and those related to the interaction between the provider and patient can predict adherence. Interpersonal factors such as provider communication skills, provision of information about the regimen and its efficacy, empathy, encouragement of patient question-asking, trust, and a participatory style of communication, among others, can predict adherence. The provider’s ability to anticipate and assist the patient in overcoming practical barriers can also predict adherence. More detailed examples of studies describing these interactional aspects will be presented.
Provider-Patient Communication and Adherence
Many of the studies cited here report qualitative rather than quantitative research. The former provide richer data but preclude the drawing of statistical or potentially causal conclusions. The nature of the topics being discussed—communication and adherence—make research allowing conclusions about causality very difficult, in any event. The most notable exception to this is the research discussed in “Interventions to Improve Adherence,” which focuses upon communicative interventions and their impact on patient adherence.
Physician-patient communication is a key predictor of patient adherence to treatment, and researchers have been studying this relationship for the past several decades. A meta-analytic review of the communication-adherence link involved a review of the relevant literature between 1949 and 2008 (Zolnierek & DiMatteo, 2009). This review attempted to answer two questions: (1) Is there a positive relationship between physician communication and patient adherence across studies? (2) Can patient adherence be enhanced through communication skills training for physicians? Communication in studies was broadly coded as task-oriented or psychosocial. A total of 106 correlational studies was included in this meta-analysis; 41 studies measured task-oriented communication (e.g., ratings by patient of physician explanations or instructions, physicians’ use of collaboration), 10 measured psychosocial communication (e.g., judgments of content-filtered voice tone), and 55 measured both. It should be noted that, although communication creates trust and trust influences communication, the two concepts are not the same thing. Findings revealed that across these 106 studies, the association between physician communication and patient adherence was positive and significant (unweighted mean r = .19, p < .001). Analysis of moderator effects showed that the correlation between adherence and communication was significantly larger under the following conditions: smaller sample size, objectively measured adherence rather than subjectively measured, physician specialty as a pediatrician, physician training status as a resident, and when communication was assessed by someone other than the patient (e.g., neutral observers). This meta-analysis was not able to show which aspects of communication are most important for adherence, and this remains an important question to answer. However, an examination of the appendix accompanying Zolnierek and DiMatteo (2009) reveals more detail about the individual studies included in this analysis and potential insights into communicative behaviors that can promote adherence. For example, several included studies showed a positive relationship between physicians giving thorough information and clear explanations and adherence to treatment in diabetes and glaucoma (Friedman et al., 2008; Heisler, Bouknight, Hayward, Smith, & Kerr, 2002). Other included studies point to the importance of active listening and positive communication for adherence to treatment across conditions (Fassaert, van Dulmen, Schellevis, van der Jagt, & Bensing, 2008; Freemon, Negrete, Davis, & Korsch, 1971). Furthermore, the majority of included studies involved patients’ self-reports of physician communication rather than observational assessments of communication (i.e., videotapes or audiotapes of physician-patient interactions).
Having established the relationship between communicative behavior and patient adherence to treatment recommendations, it behooves us to more thoroughly examine the particular aspects of communication that are most directly related to adherence. The research on this issue has investigated a number of health problems, a variety of care providers, and a multitude of cultural backgrounds in patients. A key distinction that has been identified in the literature is apparent in research in which communication variables are measured through rather specific assessment compared to those that assume it is appropriate to sum or total across a variety of communication behaviors for a measure that is referred to as “more” communication. The implication is that “more” communication is meaningful, when such an assumption would be regarded as simplistic and less-than-useful by any communication expert.
The majority of studies conducted in the last several years similarly involve patient perceptions of physician communication, which may not provide the detail or nuance of observational measures. For instance, a study of adherence to adjuvant hormonal therapy for breast cancer examined the relationship between self-reported adherence to treatment at 36 months and patient perceptions of physician-centered communication (Liu, Malin, Diamant, Thind, & Maly, 2013). These authors found a strongly positive and significant relationship between self-reported hormone therapy adherence and patient-centered communication. It is notable that there was a high (nearly 90%) adherence rate in this study population.
This topic was also addressed in work by Wuensch et al. (2015). Patients in this study had been prescribed endocrine therapy, and the results of the study indicated that a very small amount of information had been shared with the women about their treatment. The side-effects of this treatment are significant and affect daily functioning but were almost completely ignored by physicians; the data indicate that these side effects were largely responsible for lack of adherence in the patients. The authors concluded that lack of communication about several aspects of the treatment by physicians were key but easily addressable determinants of adherence, as their data indicated a strong relationship between adherence and detailed answers to the women’s questions.
Adherence to adjuvant breast cancer therapy was also addressed in work by Davidson, Vogel, and Wickerham (2007). This linguistic study of oncologist-patient discussions found that the interactants did not address potential difficulties of remaining adherent with therapy in the long term. Communications about persistence were usually monologues addressing what research has shown; they were not tied directly to the patient or to the importance of persistence and adherence. The patient’s cancer was framed in the past tense, and discussions were similar to those of chronic management in preventive medicine rather than being more specifically adapted to this context. This is a potential barrier for motivating patients to stay on hormonal therapy. Although the oncologists in this study recognized that adherence to hormonal therapy is a problem, they did not feel that their patients experienced this problem. As minimal nurse interactions were observed, the importance of communication from the oncologist is especially important.
In understanding the adherence-communication relationship, it is important to consider other populations, such as patient adherence to mental health medications for psychiatric conditions. The meta-analysis described in Zolnierek and DiMatteo (2009) excluded psychiatric populations, but a review attempted to fill this gap (Thompson & McCabe, 2012). This review included 23 studies, although the authors cited “heterogeneity of methods” as a reason for not being able to conduct a meta-analysis. Unfortunately, only one study involved examination of the relationship between adherence and objective ratings of communication, demonstrating that patients who asked more questions were less adherent. A study examining Type II diabetes patients with a new antidepressant prescription (Bauer et al., 2014) assessed associations with several patient self-reported measures of communication (i.e., trust and shared decision-making). Several measures of adherence were examined, using physician prescribing and pharmacy dispensing information; findings revealed that patients’ perceptions of lack of shared decision-making and trust were strongly associated with multiple measures of antidepressant adherence. Another study also focused on psychiatric patients, but its emphasis was on nonverbal communication (Cruz et al., 2013).
Pediatric populations are another special population for whom the communication-adherence relationship is less frequently studied. In one study, pediatric asthma medical visits were audiotaped and the following elements of communication were coded: number of medication questions asked by child and whether the healthcare professional sought parent/caregiver or child input into the treatment plan (Sleath et al., 2012). Adherence was assessed using the validated, self-reported Brief Medication Questionnaire, and one notable finding was that the medical provider’s seeking of caregiver/parent input into the child’s treatment plan was associated with better adherence reported at a one-month follow-up home visit interview. As parents or caregivers are present in pediatric visits, it is necessary to assess the communication of multiple interactants in the medical visit.
Other studies have examined modifiers of the communication-adherence relationship, such as racial background of providers and patients. A study examined race discordant and concordant physician-patient interactions, measuring adherence to antihypertensive medications with the widely used Morisky Medication Adherence Scale, and surveying patients using an adaptation of an existing measure of collaborative communication (Schoenthaler, Allegrante, Chaplin, & Ogedegbe, 2012). Findings from this study indicated that African American patients in racially discordant relationships who reported more collaborative communication also reported better adherence to antihypertensive medications, whereas white physicians’ communication that was rated as non-collaborative was related to poorer adherence. With the current emphasis on reducing disparities in medical care for patients of minority or economically disadvantaged backgrounds, this study suggests the importance of paying attention to demographic factors that may change the communication-adherence relationship and also ensuring awareness of these factors in training programs and interventions to improve communication skills. Of course, race is not always a modifier of the adherence-communication relationship. Another study that investigated patient perceptions of the extent to which patients left the physician’s office with unanswered questions found that this element of communication was not related to self-reported cardiovascular disease medication adherence as a function of patient race (Zullig et al., 2015). The issue of race is also relevant to the notion of concordance as it impacts shared decision-making, to be discussed in the section “Shared Decision Making.”
Providers other than physicians may communicate to promote adherence, and studies have examined other members of the patient’s healthcare team for their role in communicating to promote adherence. For instance, a study focused on improving adherence to medication after discharge for hospitalized heart disease patients involved an intervention in which pharmacists counseled patients on the importance of adherence and also attempted to work with patients to reduce their identified adherence barriers (Calvert, Kramer, Anstrom, Kaltenbach, Stafford, & Allen LaPointe, 2012). Medication refill records demonstrated a trend toward improved adherence to heart disease medications in the intervention group.
As several studies on communication and adherence have focused on the very important and problematic topic of HIV treatment adherence, we now move to a more specific discussion of this body of work. Communication with pharmacists, as just noted, is also relevant to this issue.
An example of a concern of research focusing on totaling or summing communicative behaviors in relation to adherence is work on HIV patients in western Kenya that was conducted by Wachira, Middlestadt, Reece, Peng, & Braitstein (2014). Although the physician communicative behaviors were not ultimately associated with physician-patient relationships as assessed by time spent with the physician, trust in the physician, and decision-making preferences, the frequency of several physician communicative behaviors was associated with adherence and health outcomes. Across the assessed physician communication behaviors, more communication was associated with higher perceived health status. Physicians tended to talk more to healthier patients. More communication was related to higher attendance at the clinic, fewer missed appointments, and more adherence to cART (Combination Antiretroviral Therapy) medications. The Wachira et al. study assessed 11 types of communicative statements and reported the frequency of each, but the analyses ignore any potential impact of each type of statement on adherence.
A similar study of HIV patients and highly active anti-retroviral (HAART) adherence was conducted in Zambia by Sanjobo, Frich, and Fretheim (2012). They determined that lack of information and communication were barriers to adherence, with a particular focus on lack of information about how to take the medication. Patients reported that physicians would write prescriptions and just hand them to the patients with no accompanying instructions, and that no healthcare provider ever inquired about their understanding of procedures or their adherence to the treatment. Some care providers indicated that they assumed that patients would get information about their medications from the pharmacy, but this did not occur. Other research has also focused on the relevance of communication between HIV patients and pharmacists (Watermeyer & Penn, 2012).
The research cited to this point has made evident the relevance of various interpersonal dimensions as they relate to adherence. A similar theme is apparent in the work of Laws et al. (2012) on HIV treatment focusing on what they called “whole person knowledge” (p. 893). The respondents, who reported stable relationships with their providers,
appreciated providers who knew and cared about their personal lives, who were clear and direct about instructions, and who were accessible. Most had struggled to overcome addiction, emotional turmoil, and/or denial before gaining control over their lives and becoming adherent to medications. (p. 893)
What is notable about these findings is the assumption on the part of patients that their adherence was an autonomous decision on their parts rather than related to provider-patient interaction.
Earlier work on HIV and treatment adherence compared patients in San Francisco and Copenhagen (Barfod, Hecht, Rubow, & Gerstoft, 2006). The providers in this study rarely initiated the topic of adherence, feeling that it was awkward to do so if there were no signs of nonadherence. Providers quickly came to question the believability of patients’ statements of adherence, however.
Fehringer, Bastos, Massard, Maia, Pilotto, and Kerrigan (2006) also provide an interesting examination of adherence-related communication between HIV+ patients on HAART medications and care providers. Questions posed by providers were generally closed and leading. Most communication was focused on biomedical issues and avoided psychosocial concerns. Patients did indicate a desire for more open and direct communication about adherence.
Beyond HIV—Other Health Problems
In a study focusing on Dutch nurses working with inflammatory bowel disease (IBD) patients the relationship between recall of information and adherence to instructions is made evident (Linn, van Dijk, Smith, Jansen, & van Weert, 2013). Patients remembered about half the information that was communicated to them, as evidenced through videotapes of the earlier interactions, and were adherent to that information that they remembered. This is true both in terms of immediate and delayed (three weeks) recall. The name and procedure for administration of the medication were generally recalled fairly well, but the impact of the medication on the patient’s daily life (which other research shows is essential for patients to understand), side effects, and medication intake advice were not likely to be remembered. Lower delayed recall scores and injection rather than pills as the intake procedure were associated with less self-reported adherence. Age was also related to lower adherence and recall. The question that is begged in this research, however, is characteristics of how information is communicated that makes it memorable to patients. Complexity of information, of course, is related to the ability of a patient to remember it, but there are also numerous other aspects of communication that may impact recall and are worthy of investigation. Given that the study included videotaped interactions of the nurses and patients, a much more detailed analysis could have been conducted about how the manner of communication related to self-reported adherence. As the authors also note, more adequate assessment of patient recall would be beneficial.
Focusing on a broader application of the notion of adherence is a body of research that centers on compliance with exercise regimens. One example is Horne and Tierney’s (2012) study of compliance with exercise regimens suggested for elderly South Asian patients in the United Kingdom. This systematic review of qualitative studies indicates a lack of understanding of information in the patients, coupled with a need for family help with support and translation as well as cultural beliefs that suggest inappropriateness of exercise for this population. It is likely that these findings have implications well beyond these patients and this cultural group.
Wright, Galtieri, and Fell (2014) also focuses on exercise; in this study of Australian patients the emphasis was on musculoskeletal injuries and home rehabilitation exercise. The provider-patient relationship was the key predictor of adherence to the prescribed exercises, and the authors suggest an increased emphasis on provider-patient communication. The two key aspects of communication that were advocated were increased information and building trust. Again, however, no particular communicative behaviors were examined. Although the authors draw conclusions about communication, an examination of the measures indicates that no assessment method utilized in the study actually focused upon communicative behavior in the sense that a communication expert would expect.
Physical exercise is an issue that is relevant to most populations, and exercise is related to the work of Polikandrioti and Babatsikou (2013) on coronary disease patients. Echoing the themes noted previously, this bibliographic review thoroughly documents the types of information needed by coronary disease patients. The authors do not, however, examine the link between the various types of information and adherence to an exercise regimen; they instead assert such a link without data. As the other data cited within this report make clear, there is no reason to doubt this link. It would have been helpful, however, for the authors to more specifically relate certain types of information with varying levels of adherence.
Although most work on adherence focuses on compliance by the patient, the concept is also relevant to home healthcare provided to others, especially children and the elderly. The work of van Elsland, Springer, Steenhuis, van Toorn, Schoeman, and van Furth (2012), conducted on home healthcare providers of children with tuberculous meningitis in South Africa, helps illuminate this process. In cultures with scarce medical resources, prolonged hospitalization is not a possibility. South Africa has an unusually high rate of tuberculous meningitis. This combination leads to an increased emphasis on home care, with a concomitant increase in adherence problems. Nonadherence is more likely when healthcare providers are not able to closely monitor patients within the hospital. This group of researchers did find a tendency for doctors to persevere to ensure adequate communication of information; this was particularly notable and surprising in light of the inordinately long waiting times at the clinic that was studied. Once again, however, the study did not enable the correlation of certain communicative behaviors with increased or decreased adherence. The relationship is assumed rather than established.
The notion of caregiver/child/provider communication and the impact on compliance in children is also the core of work by Sleath et al. (2012). These children had been diagnosed with asthma, an illness for which adherence is known to be suboptimal. Adherence was assessed by caregiver or parent reports, but it was communication between the provider and the child that was a key causal variable under examination. Provider-child communication was associated with higher adherence, but the same was true of provider-parent communication. Thus, communication from providers to both the children and the caregivers increased adherence. This study, like most of the others discussed, did not break down the findings by type of communicative behavior. The findings did indicate the importance of identifying the child’s preferences in order to increase adherence, thus leading to the focus of the section “Shared Decision Making.”
Shared Decision Making
Another group of studies has taken a more dyadic focus on the provider-patient interaction by looking at how shared decision making and adherence interrelate. Building on earlier work by Bultman and Svarstad (2000), Hahn (2009) focused on adherence to antidepressant medication and shared decision making. After articulating the problem of detecting nonadherence, he then proposed a four-step strategy to spot this. This includes normalizing nonadherence rather than stigmatizing it. This is followed by a shared decision-making process in which the provider and the patient work to determine what the patient does and does not understand about the medication and enabling the patient to feel comfortable reporting accurate levels of adherence rather than trying to hide nonadherence. The provider and the patient work as a team to make decisions and monitor behavior without perceived evaluation or judgement on the part of the provider.
The issue of race concordance between a provider and a patient may impact the likelihood of shared decision making. The interrelationships among race concordance, shared decision making or collaboration, and general concordance were investigated in the study of hypertensive patients by Schoenthaler, Allegrante, Chaplin, and Ogedegbe (2012). The findings were not simplistic, in that there was no overall significant relationship between adherence and provider-patient communication in race-concordant relationships. The relationships were different for Caucasian compared to African American patients. Perhaps race concordance or the lack thereof determines expectations for collaborative communication, which subsequently affects adherence? Evident in this study, however, is once again the lack of distinction among different collaborative communication behaviors. It cannot be assumed that all “collaborative” behaviors have the same outcome on adherence, apart from race concordance or other demographic matches or mismatches.
Race concordance in combination with language concordance was examined in research on cardiovascular medication adherence in diabetic patients by Traylor, Schmittdiel, Uratsu, Mangione, and Subramanian (2010). They found that race concordance was a key determinant of adherence in African American patients, but language concordance was more important for Hispanic patients. Caucasian patients were more adherent than were Hispanic, African American, or Asian participants. Other research has also found low adherence in Latino patients, especially those with low English proficiency (Guntzviller, 2013).
Specifics of Language Use
Overcoming the criticisms of lack of specificity of communicative behaviors are two studies that looked in more detail at actual language use as it relates to adherence. Focusing, as did Hahn (2009), on antidepressant adherence, Kaplan, Keeley, Engel, Emsermann, and Brody (2013) audio-recorded interactions between newly diagnosed depressed patients and their care providers. Several specific communicative behaviors on the part of each interactant were coded. On the part of the clinicians, statements of reflections, motivational interviewing-adherent statements (MIAs), global ratings of empathy, and what was labeled “motivational interviewing spirit” (p. 409) were coded. The focus of the assessment of patients’ communication was “change talk” (p. 409), which included statements from patients indicating intent to take the medication. All of the clinician behaviors except motivational interviewing spirit were significantly related to patients’ change talk. Pharmacy records were assessed to determine first whether patients filled the initial prescription, followed by estimates of adherence over the next 180 days. Although almost 89% of patients filled the first prescription, the follow-up estimates of adherence were closer to 45%. Uttering two or more statements of change talk was associated with 63% of follow-up adherence; zero or one such statements were associated with 36% of follow-up adherence. Empathy, motivational interviewing spirit, and change talk were all associated with filling the first prescription. Whereas MIAs, empathy, and reflections seemed to lead to patient change talk, the key determinants of filling the initial prescription and follow-up adherence were clinician empathy and patient change talk.
Another language-related issue is message framing as it affects adherence (Zhao, Villagran, Kreps, & McHorney, 2012). Many health-related messages may be framed from either a gain- or a loss-perspective; similarly, messages may be framed with a focus on the present or the future. Zhao et al. used two different message topics—one related to side effects and one related to the patient’s need for a medication—and found that the gain frame showed an advantage over the loss frame among future-oriented patients; for present-oriented patients, the framing effect was less relevant to intention toward adherence. This was true regardless of message topic.
Although most of the studies reviewed to this point have focused on face-to-face communication as it relates to adherence, work by Ellington et al. examined phone conversations between callers to a poison-control line and the poison-control experts. A sample of calls was coded using Roter’s Interaction Analysis System (RIAS; Roter & Hall, 1989), which categorizes both interactants’ statements into 48 different categories. Patients were the key determinants of the direction of the conversations; patient adherence was most strongly determined by staff partnership statements.
The nonverbal aspects of the communicative process also impact adherence. Cruz et al. (2013) report one of the few studies to look at the relationship between these two processes. They focused on depressive patients interacting with psychiatrists; they, too, used the RIAS as well as assessment of nonverbal aspects of communication. Their assessment of adherence was appointment adherence, an issue that is especially problematic for mental health professionals. They found that positive voice tone was significant in its relationship to appointment adherence. Positive voice tone was not related to appointment length or more patient-centered communication, nor were either of those variables related to adherence.
Interventions to Improve Adherence
In light of all of these studies indicating relationships between communication and adherence, it is important to target ways in which communication interventions may improve adherence. Numerous interventions have been conducted with the goal of improving treatment adherence; unfortunately, fewer than half of published interventions have demonstrated significant improvement in adherence or patient health outcomes (Haynes, Ackloo, Sahota, McDonald, & Yao, 2008; McDonald, Garg, & Haynes, 2002). One review categorized adherence intervention approaches as informational (e.g., providing some form of education to patients), behavioral (e.g., using reminders or fitting the regimen into the patient’s lifestyle), social (e.g., peer or family support), or a combination of these approaches (Kripalani, Yao, & Haynes, 2007).
A review of 182 randomized controlled trials of interventions to improve medication adherence reported that interventions addressing multiple barriers to adherence and personalizing the intervention to the patient tended to be the most successful (Nieuwlaat et al., 2014). These authors conducted a qualitative analysis, commenting on the heterogeneity of interventions and the issues of bias in study design and methodology in many of the studies. Accordingly, the findings suggested that some of these complex and personalized interventions involved persistent support from healthcare providers, such as counseling and patient education. A narrative review of interventions suggested that effective interventions involve clinicians engaging in the following behaviors: simplifying the regimen, working to enhance patient understanding of the regimen, addressing patient beliefs, improving provider-patient communication, and effectively measuring adherence (Atreja, Bellam, & Levy, 2005).
Rochon, Ross, Looney, Nepal, Price, & Giordano (2011) addressed interventions with HIV+ patients. Their qualitative results indicated five constructs—cultural beliefs and language, stigma, cues to action, self-efficacy, and mood state—that may be modified by communication strategies. On the basis of these, their ongoing work involves the development of an adherence-related social marketing campaign. Responding to this essay, however, de Bruin (2012) cites data indicating more effectiveness of HIV adherence interventions than presented by Rochon et al.
As was noted in regard to exercise regimens, adherence to dietary plans is another especially difficult problem for many patients. Focusing on this issue, Desroches, Lapointe, Ratté, Gravel, Légaré, and Turcotte (2013) conducted a systematic review of 38 randomized control studies, with a particular focus on the relation of diet to chronic disease. They found that most of the studies were poorly done and of short duration; few showed statistical differences between the intervention and control groups. Measures of adherence varied widely. Only 32 out of 123 diet adherence outcomes favored the intervention group. Those studies that reported a significant effect of an intervention in the short term rarely did so in the longer term. Studies using interventions such as group sessions, individual sessions, reminders, restrictions, and behavior change techniques were particularly ineffective. Some positive results were noted for investigations using telephone follow-ups, videos, contracts with rewards, feedback, and nutritional tools. More complex interventions including multiple manipulations were common. The Desroches et al. report is a very thorough presentation of the relevant research and will be of great interest to researchers and practitioners focusing on this topic.
In addition to the various types of interventions just noted, several studies have focused on technology-assisted strategies to impact adherence. One useful example is Wu and Hommel (2014), which presents a summary of some of this research on the pediatric population with chronic diseases. The ease of eHealth and mHealth (through mobile devices) technology makes such interventions a useful option in the attempt to impact adherence, especially in a younger population that is generally comfortable with technology. Research has indicated effective applications of text messaging, SmartPhone applications (which allow monitoring and encouragement of adherence as well as social media networks), electronic monitors of adherence (which can also be programmed to send reminders to patients), and illness-specific devices, such as those adapted to diabetic patients. Wu and Hommel note several relevant issues that cut across technologies as well as some that are unique to each. Their overall conclusion, however, is that eHealth and mHealth technologies are very useful for both monitoring of adherence and for encouraging adherence through reminders. These technologies show much more applicability for tailoring messages to particular patients, which is especially important for influencing adherence. Not all patients respond to any message in the same way, and the growing body of research on tailoring is particularly relevant to a focus on communication and adherence.
Tailoring was also central in the work of Blake, McMorris, Jacobson, Gasmararian, and Kripalani (2010), which focused on medication adherence in poor and underserved patients. Noting the lower literacy levels in these patients, Blake et al. developed and tested an intervention that consisted of an automated telephone call reminder system, an illustrated medication schedule tailored to each patient’s medications, and pharmacist training in clear health communication. The messages were personalized to the special needs and interests of the target population. The communication training focused on avoiding medical jargon, emphasizing a few key points, and asking patients to re-state the information in their own words to assess patient comprehension. Although the study was designed to improve adherence, actual patient adherence was not reported in the results. Pharmacists and patients did both respond positively to the intervention, however.
Technological interventions have also been of great interest to care providers who treat patients with asthma, another area in which adherence is a notable problem. Tran, Coffman, Sumino, and Cabana’s (2014) systematic review of research on this topic found that electronic reminders were associated with greater levels of participant asthma medication adherence in comparison to those in the control group. None of the studies, however, demonstrated that the reminders were associated with changes in asthma-related quality of life or clinical asthma outcomes.
Communication Skills Training
Yet another intervention approach related to the study of communication and adherence is that body of work that focuses on training either providers or patients in communication skills. The meta-analytic review described earlier that examined the relationship between communication and adherence also examined whether patient adherence can be improved through communication skills training for physicians (Zolnierek & DiMatteo, 2009). A total of 21 studies listed patient adherence as an outcome of a physician communication skills intervention. Across these 21 studies, the effect of physician communication skills training on patient adherence was positive and significant (r = .12, p < .001). One interesting moderator analysis revealed that when communication training was explicitly focused on patient adherence, there was a marginally significant effect of communication skills interventions on adherence. This suggests that it may be valuable in communication interventions to provide training about adherence and how to communicate about this challenge.
Consistent with several of the studies noted is the work of Broers, Smets, Bindels, Evertsz, Calff, & de Haes (2005), which also examined asthma. They focused on general practitioners and developed a communication training program based on behavior change counseling; this is a technique derived from motivational interviewing. Unfortunately, no adherence outcome measures were utilized in this study, but the results did indicate positive attitudes on the part of the GPs toward the approach and self-reports of use of the counseling techniques they had been taught. This is another case in which it is surprising that adherence was not assessed, as it appears to be a primary interest in the study.
Another study focused on adherence to infection control procedures during patient transfers. Ong et al.’s (2013) intervention utilized two manipulations: a pre-transfer checklist used by radiology porters to confirm a patient’s infectious status; and a colored cue to highlight written infectious status information in the transfer form. Both interventions were effective, although combined they were only slightly more effective than either alone. The colored cue intervention was more acceptable to the porters than was the checklist procedure.
In an examination of management of pain, Butow and Sharpe (2013) noted that one of the problems in pain management is lack of patient adherence to treatment regimens. Their review of the relevant literature indicated several communicative interventions that may impact such adherence; all of these focused on tailoring messages to patients’ reasons for lack of adherence. Consistent with several of the studies noted, they found that a nonjudgmental approach, allowing open exploration of patient beliefs and concerns, and use of a negotiating approach that fosters shared decision making are essential.
Lonsdale et al. (2012) describe a rather interesting communication skills training program called CONNECT that is focused upon the relationship between provider skills and patient adherence. This program relates to the difficulty of compliance with exercise regimens already noted, but emphasizes application to patients with chronic low back pain. Based on self-determination theory (Ryan & Deci, 2002), the communicative behaviors emphasized in the training are those related to autonomy-supportiveness from physiotherapists toward their patients. Subsequent work by these authors and their colleagues (Murray et al., 2015) indicates support for this system; communicative behaviors were assessed using the Health Care Climate Questionnaire (HCCQ), which requires raters to judge physiotherapists’ needs-supportive communication while listening to audiotaped recordings. The HCCQ involves the judgement of five types of communicative behaviors: asking, advising, agreeing, assisting, and arranging. Each of these categories also includes subcategories of statements, all of which are targeted toward certain psychological needs of the patient. There was a notable effect size difference between the intervention group and the waiting-list control group.
Hahn et al. (2010) utilized a sociolinguistic perspective to study communication skills training and detection of adherence in patients with glaucoma. The intervention used videotaped vignettes and role playing to encourage the development of patient-centered communication skills, including a four-step adherence assessment process and the use of open-ended questions in ask-tell-ask sequences. Physicians who had participated in the training asked more open-ended questions, especially about whether patients had taken medications. Both the advised ask-tell-ask sequences and discussions about adherence were significantly more common after training. Physician elicitation of adherence was also three times more likely after training. This is important in light of the findings that many physicians do not include relevant aspects of persuasive recommendations in their messages to patients (Feng, Bell, Jerant, & Kravitz, 2011).
Patient communication training
Although most of the studies on communication skills training and adherence have focused on care providers, a small body of research has examined the impact of communication skills training in patients on adherence. Cegala, Marinelli, and Post (2000) manipulated training patients about effective communication a few days prior to their scheduled appointment through a written brochure vs. informing the patients about the relevant information in the waiting room prior to their appointment. An untrained/uninformed control group was also included. Training through the written brochure increased patient compliance more than did either of the other two conditions. Thus, patient adherence can be addressed by targeting both provider and patient behaviors.
What is clear in the research cited is that there is an important relationship between communicative behavior and the very problematic issue of patient treatment nonadherence, and that some interventions focusing on communication can impact adherence. Those are two very important conclusions. Also notable in our assessment of this research is that communicative behaviors are too frequently inadequately assessed or addressed in this body of literature. It is fortunate that some of the studies cited within conceptualize and measure communication more adequately than do others; however, many of the studies are simplistic in their theoretical approach and operationalization. Some of the studies claim to address communication when they do not do so at all.
The same is true of the operationalization of adherence or compliance. This key outcome variable may be assessed in a multitude of ways, some of which are more useful and appropriate than are others. And terminology can vary across disciplines and in different areas of medical treatment. Several of the studies reviewed, however, do not measure adherence in any way. Relationships are assumed rather than assessed.
It will continue to be important to parse out which specific aspects of communication are most beneficial for adherence. Studies reviewed here describe the following aspects of communication as related to adherence: patient-centered communication, detailed information–giving, shared decision making, collaborative communication, open discussions, empathic communication, and positive voice tone. In light of these findings and other research showing the communicative behaviors most important to adherence, future adherence interventions related to provider-patient communication should be designed accordingly.
Two areas of research that seem especially promising in terms of communication and adherence are those approaches based on tailoring to patients or patient groups (frequently called targeting) and those newer approaches that rely on technology for reminders and monitoring. These two approaches work nicely together, but it is likely that they work best when used as supplementary to the interpersonal aspects of communication noted earlier. The work on the relation between interpersonal and mediated aspects of communication is consistent in noting the interrelationships between the two, and that the most impactful health communication uses both channels of communication (Southwell & Yzer, 2007). Indeed, personalized, targeted interventions are ideal, as each patient faces a different set of barriers to adherence; furthermore, the potential for interaction, monitoring, support, and encouragement via smartphones and other technology is great. Ongoing and future research will show the extent to which these technology-based interventions make a difference for patient adherence.
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