Nonetheless, research suggests non-adherence is as normal as adherence across most therapeutic areas.* Whether adherence program work depends on our ability to break patients’ barriers to adherence.
Non-adherence is a testimony to the complexity of human psychology and the practical realities of our everyday life. As we try to define what tools to implement in order to drive adherence, we need a model to understand human psychology and our existence in the context of barriers to adherence. Literature and academia offer a range of models on behavioral science.
Here is a synthesized, pragmatic Adherence Barrier Model for scoping and developing Multi-Channel adherence programs. Note, the model is practical and geared to this specific purpose only.
When developing an adherence program, you need to investigate the prevalence and impact of the following types of barriers:
First, subconscious barriers. These lies deep in our DNA or are ingrained in our psyche through extreme and early experiences. “Fear of the unknown” is an example of such. A disease journey is a journey into the unknown and the unpredictable, and select individuals subconsciously resist physical confirmation that they are undertaking such journey e.g. by taking a pill. Therapy is often used to uncover such.
Second, conscious, emotional barriers which we are often immediately able to talk about. These are the ones captured in Beliefs about Medicines Questionnaires and similar; can be unveiled through face-to-face interviews or, on an aggregate level, via social media analysis. Many of these are inherited from the subconscious barriers and beliefs. An example of such is distrust of the doctor / medical authority. This may manifests itself as self-diagnosis via Google and resistance to following expert medical advice.
Third, practical usage barriers such as lacking injection technique, shape of pill (reflux), incapacitation due to side effects and similar, where practical measures can be used as a remedy.
Fourth, practical external factors including the patient being too busy to take the pill or attend consultations; the patient is simply generally forgetful; or application for reimbursement is cumbersome, etc.
These different type of barriers require different barrier busters in order to improve adherence.
A typical, reductionist, and sometimes effective approach is choosing ignorance on the part of the patient as the primary barrier you need to bust in order to improve adherence.
The argument may go that the patient does not currently comprehend the importance of taking the medicine as prescribed for ensuring a positive health outcome. Or at a more advanced level, the patient mistakenly thinks that side effects experienced indicate that the drug is not working. When assuming a positive relation between knowledge and adherence Pharma is often led to the conclusion that we should teach the patient about the drug and adherence will ensue.
However, this approach presupposes that the patient is motivated to receive education. In this matter, we can add to our understanding by referencing the Trans-Theoretical Model of Change which describes change as a process.
A patient may be prescribed to a product before having emotionally accepted that she is ill. Take the example of a patient prescribed to a drug within Alcohol Dependence. Any discussion on the CNS disease makes her defensive mechanisms and trigger arguments such as “nobody in my family has ever died from excessive drinking”. She is unlikely to respond well to receiving a nicely designed, personal patient leaflet providing instructions on How to Stop Drinking. She first needs to recognize that she is suffering from a disease and that the consequences of her life are unacceptable before engaging with content regarding a solution to such problem.
Another assumption behind the educational approach is that knowledge drives beliefs which drives behavior. Whereas this logic applies sometimes, I need look no further than myself to understand its limitations. For example, I know why I should work out or drink water rather than processed or sugared drinks. Frankly, my behavior deviates rather dramatically from my knowledge. In this context I am partially the slave of the human reward system which favors immediate gain over long time gains.
The traditional approach of simply providing the right pieces of information at the right time doesn’t take into account the natural mental barriers that patients have to consuming, absorbing and internalizing such information. We must employ coaching, and activities so that patients can learn to arrive at certain conclusions on their own. Information should of course also be provided so that patients can make use of it when they’re mentally ready.
One of the simple credos often used in explaining the tools of change is Benjamin Franklin’s infamous “Tell me and I will forget; Teach me and I remember; Involve and I learn”. Whereas, it is arguably an oversimplification, it can be used to provide an overall framework for which type of barrier busters to use for different types of barriers.
Teaching and Involving are most useful when addressing subconscious and emotional barriers, as these are activities that drive self-understanding. Emotions must be understood and processed from within. As the barriers become more practical, simple information and informational tools can be more effective e.g. a SMS reminder system for the forgetful patient in the Maintenance stage of the Trans-Theoretical Model of Change.
On a crude level, different tools and types of content can be categorized according to Franklin’s saying. The following chart shows some activities / content that fits into the Tell, Teach and Involve categories…
Different studies have shown that a human, face to face coach/nurse is next to none in terms of improving adherence. However, in a practical world of limiting logistics and finance, digital can supplement in a variety of ways.
Several studies show that patient adherence program do have a positive impact on adherence. However, as presented above, the complexity of busting adherence barriers is greater than we would want. At base level there is an ironic tension in trying to make patients adherent to an adherence program. Nobody has found the silver bullet yet but what excites me about digital is the seamless and transparent way in which it integrates into our lives. Digital pushes us towards a world where our intricate psychology and logistical complexity need not come in the way of therapy adherence goals.
*The National Centre for Biotechnology Information, 2018
** Cultural Issues in Medication Adherence: Disparities and Directions
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