The importance of medication adherence is widely understood by health care professionals and the general populace. Nonadherence is linked to poor health outcomes, including a decreased quality-of-life, disease progression, and increased hospitalizations.
However, research has demonstrated that somewhere between 25% and 50% of patients internationally may be nonadherent to prescribed medication for several reasons, such as:
- Forgetting to take medication for a day or a span of days
- Deciding not to take medication for a day or a span of days
- Taking a lower or higher dose than prescribed
- Neglecting to fill their prescriptions on time (or ever)
- Substituting an over-the-counter (OTC) medication for a prescribed medication
- Taking medication with another medicine or supplement with which it could interact
Patient education, support, and engagement programs designed to improve adherence to medications have become a mainstay in the outreach strategies of pharmaceutical companies in the United States, the UK, and the EU. Most of these programs utilize effective communication techniques, such as ongoing and well-timed messaging, and access to expert and highly trained representatives, such as nurses and pharmacists, through multiple channels that may include telephonic, digital, virtual, and in-person methods.
However, these programs often do not fully recognize that the reasons for nonadherence may be complex and driven by each patient’s cultural and social perspective. No matter how elegantly designed, competently delivered, and expensive the program may be, it will more than likely miss the mark if it does not have at its core an effective way to understand the patient’s belief system and the underlying reasons for nonadherence.
Although there is no one-size-fits-all set of messages that will significantly move the needle on adherence, the use of a behavioral science model—which focuses on understanding an individual’s beliefs about their disease and prescribed treatment—can be of great impact.
One such model that can be utilized is COM-B, which is a framework for understanding human behavior in a defined situation. Created by British psychologist and professor Susan Michie 1 and her colleagues, this model groups behavioral influencers into 3 main components: 1,2
- Capability: A person’s physical and psychological capacity to engage in a behavior.
- Opportunity: The factors outside the person’s direct control that either prompt a behavior or make it possible.
- Motivation: The processes of the brain that direct behavior.
Through this model, barriers to and facilitators of specific behaviors are identified and approaches are developed, including education and training 2 (both of which are components of patient engagement programs), modeling the desired behavior by sharing an aspirational example, and enabling behavior changes by providing opportunities or eliminating roadblocks.
COM-B has many applications, including the improved use of medicines and other recommended treatments. Patients can be intimidated by being asked direct questions (e.g., “Are you being adherent to your medication?”) and may be reluctant to answer completely honestly. A more effective approach that acts as an example of COM-B in action is to use a series of statements that allow patients to indicate whether they are experiencing any problems with their medication.
These statements are developed by behavioral science experts and are based on the disease state and the prescribed treatment. They could be presented to a patient verbally or in writing through the pharmaceutical company’s education, support, and engagement program (or by another stakeholder organization such as an insurer) and are typically answered using a scale that measures the respondent’s agreement with the statement. Examples of statements that could be used include:
- My medicine is difficult to use
- I cannot manage so many medications
- I am not sure if the medicine is really helping me
- I have concerns about using the medicine
- I cannot afford the time to get the medication
- I cannot afford the medication
- I have found my own way to use the medication that suits me
Using interpretation tools grounded in behavioral psychology, an analysis of the responses would then be created and shared with the patient, encouraging them to discuss the results with members of their health care team. This patient and health care professional (HCP) communication fills a gap that too often exists between HCP and patient, as the HCP may be unaware of the challenges the patient is facing. Through this process, HCPs learn the tenets of behavioral science as they relate to their patients’ relationship with their prescribed medication.
A behavioral science model such as COM-B can also be used to glean information about a patient’s overall attitudes toward their health, which may be driven in part by their cultural beliefs. These attitudes play an important role in their health behaviors, including medication adherence.
Some statements related to health attitudes:
- I tend to self-diagnose my illnesses
- I tend to self-treat my illnesses
- I rely on home remedies more than OTC or prescription medications
- I rely on OTC medications more than prescription medication
- I seek out medical advice from my friends and family
- I rely on medical advice from my friends and family more than I rely on medical advice from my doctor
- It is important to me that my relationship with my doctor is friendly as well as professional
As with the statements specific to adherence, an analysis of the responses would be created for discussion between the patient and their HCP. This alignment of HCP and patient can have a beneficial effect on the patient’s health outcomes by increasing their level of satisfaction with their care, and in turn their willingness to disclose their complete medical history, to adhere to treatment, to report adverse effects and to maintain an optimal schedule of follow-up appointments.
Additionally, another area for assessment is a patient’s preferred communication method. Certain statements can be presented to ascertain this method, with the responses analyzed in the context of a behavioral science model:
- I would rather get information from a member of my health care team than from the pharmaceutical company that manufactures my medication
- If I were to contact a pharmaceutical company, my preference is to talk to a person
- If I were to contact a pharmaceutical company, my preference is to communicate via email
- If I were to contact a pharmaceutical company, my preference is to communicate via text
- If I were to contact a pharmaceutical company, my preference is to get information through some self-service method (recorded messages, website)
- I am comfortable communicating via digital means
In regard to the use of technology in this context, recent studies have shown that the use of mobile devices to collect information from patients (including about their medication adherence), can be an effective approach—and one that is also grounded in behavioral science. Many patients find it more comfortable to be candid when completing a digital health behavior assessment than when answering direct questions posed by their HCP. That candor then paves the way for a more productive and outcome-oriented discussion during the in-person or telehealth visit.
By incorporating behavioral science principles in their own patient-facing programs, pharmacy can have a significant impact on improving health outcomes. Additionally, they can strengthen their relationships with HCPs by offering customized training on the role of behavioral science in identifying and addressing individual motivators and barriers. This training, which can be developed in partnership with behavioral science experts, will also be of value in enhancing communication between HCPs and their patients.