By Dr. Nwamaka Osakwe
Treatment adherence refers to the degree to which a patient correctly follows an agreed recommendation from the health care provider. It includes taking medications and following recommendations for diet and lifestyle changes.
According to the World Health Organization, hypertension affects 1.4 billion people worldwide. However, despite the global burden of hypertension and the severity of the outcome, only 14% of individuals with hypertension have their blood pressure under control. According to one systematic review, the situation is worse in Africa, where only 7% of individuals with hypertension are under control.
Poor adherence is linked to suboptimal blood pressure control and its attendant consequences. These consequences include health complications (heart failure, chronic kidney disease, myocardial infarction, and stroke), poor quality of life, disability, lowered productivity, increased economic burden, and death.
As such, treatment adherence is essential in the management of hypertension. In this blog post, you will learn strategies you can use to improve patient adherence in your clinical practice.
Causes of poor adherence
Poor adherence to medications generally occurs in any of the following circumstances when patients:
- fail to begin their medications
- do not take their medications as prescribed
- discontinue the medications
Patient-related factors
The patients’ beliefs can impact adherence, the need for therapy, and the perceived side effects of treatment. In addition, because hypertension is often asymptomatic, it is difficult for patients to appreciate the importance of therapy and good blood pressure control.
Furthermore, some patients forget to take their medications. Others are afraid of the long-term effects of treatment and may prefer not to take medications. In addition, some patients opt for alternative therapy rather than conventional drugs. This is often because they perceive alternative therapy to be safer.
Another factor affecting adherence is the presence of comorbid conditions like depression, dementia, and disability. Poor social support is also implicated in poor adherence, with the risk of non-adherence being greater among people who are homeless or who have unstable homes.
Other risk factors for suboptimal treatment adherence are poverty and being of a minority race.
In general, young adults and older individuals have more difficulty complying with treatment.
Therapy-related factors
Therapy-related causes of poor treatment adherence include complex regimens, frequent treatment changes, frequent refills, the side effect of medications, and treatment failure.
When patients are placed on complex regimens requiring multiple drugs taken at different times of the day, they may have difficulty complying with dose instructions. Similarly, frequent treatment changes affect drug adherence. A study found that patients whose regimens are adjusted less frequently are more likely to stick to treatment. In addition, patients who experience no adverse effects from treatment are more likely to adhere than patients who experience adverse events.
Patients are also less likely to comply with treatment if they have to refill their prescriptions too often.
Treatment failure can, in some cases, be linked to poor adherence. When patients judiciously take their medications, they expect to get better. However, if patients experience no improvement in their condition, they may become discouraged and stop complying with treatment recommendations.
Healthcare system-related factors
Experts report that the relationship between the patient and the healthcare provider and the healthcare provider’s communication style affects adherence.
A patient-centered approach is best. Patients who participate in decision-making about their prescribed medications are more likely to adhere to treatment than those not involved in the decision-making process. In addition, trust is essential in healthcare delivery.
Additionally, the cost of care and medications are essential factors in adherence globally. This is especially vital in Africa, where many people pay out-of-pocket for health care.
Strategies to improve treatment adherence
The International Society of Hypertension recommends evaluating adherence at each visit. This is even more important before increasing or altering the current treatment regimen. According to the former United States Surgeon General, C. Everett Koop, MD, “drugs don’t work in patients who don’t take them.”
Here are some strategies to improve medication adherence.
1. Patient-related strategies: Patient education and counseling
- Patient education is critical in driving adherence. Because hypertension is often asymptomatic, patients must understand its short-term and long-term effects and potential complications. During a consultation, encourage patients to restate the benefits of antihypertensives to ensure their understanding.
- Counseling allows clinicians to identify potential barriers to drug adherence and discuss how to overcome them. For example, if a patient cannot afford prescribed medication, it may be best to prescribe cheaper yet effective alternatives.
- Part of patient education should include potential side effects of antihypertensive medications. During consultations, enquire about side effects as this is a frequent cause of non-adherence. For example, men who experience erectile dysfunction while taking thiazide diuretics may stop taking their medications. The healthcare provider may discuss side effect management options or an alternative treatment option.
- Encourage patients to self-monitor their blood pressure as this helps to keep them motivated. Validate automated blood pressure devices and teach patients how to check blood pressure.
- Where possible, involve family members and provide social support. For example, what does a low salt diet mean for the family? Would it require cooking separate meals? In addition, family members can remind the patient to take their medication. Pillboxes with special packaging can also function as reminders for patients.
- Encourage patients to use reminders or alarms as part of the strategy to improve adherence. This helps to lower non-adherence from forgetfulness.
2. Drug regimen: Simplify
- Drug regimens should be simplified as much as possible. Where possible, prescribe a once-daily regimen. A fixed-dose combination pill is best for patients who require more than one medication to control their blood pressure, as this lowers the pill burden and promotes adherence. Prescription instructions should be written clearly and also communicated verbally.
- For patients with insurance, prescribe medicines covered by the insurance policy to lower out-of-pocket costs. Use cost-effective medicines for patients who pay out of pocket, and consider prescribing drugs for longer intervals to reduce refill frequency.
3. Health care system: Use appropriate communication techniques
- Health care providers should learn appropriate communication techniques when educating patients and evaluating adherence. Audiovisual educational techniques are used in many settings.
- Communicating with patients about adherence should be nonjudgmental, supportive, collaborative, and compassionate. Aim to individualize patient teaching to address specific needs (such as language, culture, communication style) and preferences.
- Using circular, reflexive, and motivational interviewing techniques improves adherence in patients with hypertension. For example, asking questions like “are you having any problems with your medication” is more effective than asking “are you taking your medication.” Asking, “are you having any problems with your medication,” presents an opportunity to collaborate with the patient. By exploring problems patients report, such as the high cost of medications or adverse effects, the clinician and patient can work together to find a solution that works.
- Organize and structure the clinical practice so that healthcare providers are not frazzled. Burnt-out clinicians, nurses, and pharmacists cannot implement strategies to promote adherence.
Bottom line
Hypertension is a serious condition that requires lifelong treatment, and non-adherence to treatment leads to poor health outcomes and substantial economic costs.
Patients may be non-adherent to treatment for several reasons, including lack of knowledge, forgetfulness, and comorbid conditions.
Therefore, healthcare providers should learn appropriate communication techniques when educating patients and evaluating adherence. In addition, treatment regimens must be simplified and patient-centric to improve adherence and outcome.
To learn more about hypertension from the World Health Organization, click here.
For patient teaching infographics, click here.
Click here for the World Health Organization Guideline for the pharmacological treatment of hypertension in adults.
For a list of blood pressure medications, click here.
Where available, it is advised to follow the Ministry of Health guidelines in your local setting.
Nwamaka Osakwe, FWACP, MBBS, is an award-winning physician who loves writing about health and wellness. You can reach her here.
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