Intentional and unintentional medication non-adherence: A comprehensive framework for clinical research and practice? A discussion paper

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Abstract

Non-adherence to medications is a prevalent and persistent healthcare problem, particularly for patients with a chronic disorder. Researchers have endeavoured to address poor adherence for the past five decades resulting in the accumulation of a vast body of literature. Despite the enormity of research conducted, interventions to date have neither been cost-effective nor predictably clinically effective in enhancing medication adherence. Though concerning, such contemporary information serves to refocus attention on the adequacy of knowledge regarding the factors influencing medication non-adherence.

Although little consensus exists regarding the optimal categorisation of these influencing factors, increasingly, the broad and ‘all encompassing’ categorisation of intentional and unintentional factors is being used to account for patient medication-taking behaviours and actions. An extensive review of the related literature provides the basis for a critical discussion on the value and comprehensiveness of this current classification in guiding future adherence research and consequent clinical interventions. An appraisal of this categorisation is important if decisions regarding interventions are not to be made in a vacuum of insufficient understanding, which would result in the continued ineffective use and distribution of valuable resources to combat non-adherence.

Section snippets

What is already known about the topic?

  • Medication non-adherence is a widely acknowledged and persistent concern for all healthcare professionals.

  • Medication adherence holds particular significance for individuals diagnosed with chronic conditions. Although key to disease and symptom management, poor adherence to long-term pharmacotherapy can be expected in up to 50% of all patients.

  • Despite five decades of research, current interventions do not consistently enhance patient adherence.

  • The simultaneous consideration of the intentional

What this paper adds

  • The intentional and unintentional dimensions of patient medication-taking are poorly categorised within adherence literature; this paper addresses this oversight by examining the key factors and literature in relation to each dimension.

  • Patients ‘irrational’ or ‘unconscious’ decision-making processes must be recognised as playing a role in impacting on the individual's ability to follow healthcare recommendations regarding medications.

  • Nurses, by understanding the complexities associated with

Intentional non-adherence

An intention is most simply characterised as the determination to act in a certain way (Merriam-Webster Collegiate Dictionary, 1998) and is an element of behaviour of every human being including health behaviour (Burks, 2001). There is an underlying assumption within this categorisation of influencing factors that patients undertake an active, reasoned decision-making process in relation to following or disregarding professional advice (Playle and Keeley, 1998; Lahdenpera, 2000; Lowry et al.,

Unintentional non-adherence

Although there is no one definitive description of unintentional non-adherence, there is an underlying assumption that this behaviour is the result of a passive process which is less strongly associated with individuals’ beliefs and cognitions than factors related to intentional non-adherence (Wroe, 2001; Lowry et al., 2005). Several factors in relation to unintentional non-adherence have been described by different authors in different ways. Rau (2005) suggests that misunderstanding the

Intentional and unintentional non-adherence: simultaneous examination

Support for a reconceptualisation of non-adherence can be observed in recent adherence literature. Johnson (2002) for example, developed the Medication Adherence Model (MAM), which derived from a qualitative study with 21 elderly people concerning their personal adherence and non-adherence and claims to take into account both the intentional decision to miss medications and the unintentional interruptions that cause medications not to be taken. Three core concepts of the model, Purposeful

The role of ‘irrational thinking’ and ‘unconscious mental processing’

Current prevailing theories surrounding health/adherence behaviour decision-making, particularly social cognitive theory, have served to provide valuable insights into critical variables underlying behaviour. However, the models within this theory have a common basis in the assumption that behaviour is rational (Messer and Meldrum, 1995). For many years the predominate view in social sciences had been that the rationality assumption is an adequate approximation for predicting human behaviour (

Conclusion and recommendations

Recent research acknowledges the urgent need for a new and more comprehensive model of adherence which is responsive to the unique requirements of the individual (Wroe, 2001; Johnson, 2002; Lehane and McCarthy, 2006). From the literature reviewed it is clear that both the intentional and unintentional dimensions of medication-taking account for a considerable percentage of the variance associated with non-adherence. The factors associated with unintentional non-adherence, particularly in terms

Acknowledgements

The research on which this paper is based is supported by Merck, Sharpe & Dohme (Ireland) Ltd., but the views expressed are the authors alone.

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