Intentional and unintentional medication non-adherence: A comprehensive framework for clinical research and practice? A discussion paper
Section snippets
What is already known about the topic?
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Medication non-adherence is a widely acknowledged and persistent concern for all healthcare professionals.
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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.
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Despite five decades of research, current interventions do not consistently enhance patient adherence.
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The simultaneous consideration of the intentional
What this paper adds
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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.
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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.
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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.
References (104)
- et al.
Electronic pill boxes in the evaluation of antihypertensive treatment compliance
American Journal of Hypertension
(2000) Predictors of medication adherence in the elderly
Clinical Therapeutics
(1998)- et al.
Determinants of compliance with medication in patients with rheumatoid arthritis: the importance of self-efficacy expectancies
Patient Education Counselling
(1999) Reactance theory and patient non-compliance
Social Scientific Medicine
(1997)- et al.
Coping and medication adherence
Journal of Affective Disorders
(2000) - et al.
Correlates of healthcare satisfaction in inner city patients with hypertension and chronic renal insufficiency
Social Science & Medicine
(1995) - et al.
taking antihypertensive medication—controlling or co-operating with patients?
International Journal of Cardiology
(1995) Compliance with treatment regimens in chronic asymptomatic diseases
American Journal of Medicine
(1997)- et al.
Compliance and antihypertensive efficacy of amlodipine compared with nifedipine slow-release
American Journal of Hypertension
(1998) - et al.
A systematic approach to educating elderly patients about their medications
Patient Education and Counselling
(1992)