A Remedy for Intentional Rx Non-Adherence – Understanding Patients’ Beliefs

Patient non-adherence is a big problem.  Non-adherence among chronic disease patients is associated with higher rates of hospital re-admissions, higher costs and poorer outcomes.

Research has identified over 200 possible factors thought to influence patient adherence.  According to the experts, these factors can be categorized into two groups:

  1. unintentional non-adherence
  2. intentional non-adherence.

Unintentional non-adherence is related to a patient’s ability and resources to take their medication (e.g., problems with manual dexterity,  forgetfulness, inability to pay for medication, etc.).  Intentional non-adherence is associated with a patient’s motivation and beliefs, e.g., the reasons for needing a medication, the efficacy of a proposed treatment, concerns about side effects and so on.

Patient-Center Communication and Diabetes – An Example

One of the basic tenets of the patient-centered care model is getting to know the “person behind the patient label, i.e., their health motivations, attitudes, beliefs and so on.  Why?  It is because people that show up in the doctor’s office each have their own pre-existing set of experiences, knowledge and beliefs about their health and the health care system.

A patient’s motivations, attitudes and beliefs are shaped by a variety of experiences.  Maybe they had a family member or friend with the same health condition.  Maybe they saw or heard a TV or radio commercial.  Or maybe they had a previous bad experience with another provider.   Regardless of where this thinking come from, or whether it is “right or wrong,” patient thinking plays an important yet often overlooked role in patient adherence.

Take the following “beliefs” expressed by a type 2 diabetes patient on a diabetes social networking site:

I keep reading where (having) type 2 diabetes is virtually a certainty for heart disease and an early death. These may be the statistics but l just haven‘t witnessed this in my personal life. My grandfather, a type 2 from his mid-40s lived to be 86. My father and two of his brothers were/are type 2 and my father lived to 83, his brother to 82, and one living brother just turned 80.  These guys have out lived/are outliving most of their friends who are not diabetic.

To my way of thinking, if you read and put a lot of faith in articles like this you might as well throw your arms up and say “I give up…I’m doomed and nothing can save me.”

If you were this person’s physician, would you find it helpful if you knew this was how your patient thought?  How adherent would you expect someone like this to be if you prescribed medication to lower their risk of heart disease (BP or cholesterol)?

Not very, I expect…

The Facts

Approximately 50% of diabetes patients are non- adherent when it comes to taking diabetes-related medications according to a 2008 study by Heisler, et al.  Up to 70% of non-adherence is thought to be intentional according to researchers.

For whatever reason, lack of time, competing priorities, perceived lack of importance, etc., physicians don’t often ask patients about their health beliefs concerning their condition, treatment efficacy, or concerns about side effects.  Probably even fewer patients volunteer such information.  Such information is simply not relevant to the bio-medical, physician-centered model of care.

Makes You Wonder

It certainly makes you wonder…

  1. to what degree patient outcomes could be improved?
  2. how much money could be saved?

…if physician better understood what makes their patients “tick?”


Clifford, S. et al.  Understanding different beliefs held by adherers, unintentional non-adherers, and intentional non-adherers: Application of the Necessity–Concerns Framework. Journal of Psychosomatic Research 64 (2008) 41–46.

Westbury, J.  Why do older people not always take their medications?  The Pharmaceutical Journal 2003.

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2 responses to “A Remedy for Intentional Rx Non-Adherence – Understanding Patients’ Beliefs

  1. Ellen H. Ullman, MSW

    There could certainly be a third oval in the diagram above – Provider Induced Non-Adherence. Absent from this post (perhaps included in what you call “for whatever reason” above) is that the physician/provider may in fact exacerbate “non-adherence”. Lack of empathy, focus on the numbers of lab results, threats of complications, judgment etc., during an office visit (or over the phone), often sets a patient up to feel he/she has already failed (so why bother?), and has an enormous impact on how a patient may or may not manage a chronic disease. Physicians and other health care providers need to look specifically at what they do, and do not do, that negatively influence patients and ultimately the patients’ health care outcomes. This includes non-verbal communication as well.

    Adherent physicians empower patients.

    Suggested reading: Motivational Interviewing in Health Care by Rollnick, Miller & Butler is a very good introduction to the art of appropriate conversation between patient and provider.

  2. Pingback: A Remedy for Intentional Rx Non-Adherence – Understanding Patients’ Beliefs | healthcare technology | Scoop.it

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