This is a complicated one - to some extent it depends on why the patient is non-adherent in the first place (i.e. intentional or non-intentional). There are lots of reasons a patient might be not taking meds, and research that I have come across to date has very mixed findings. I think this is an area where you need interventions that are tailored to the patient to help them overcome the barriers to taking meds. E.g. if it a memory issue then promts/cues/alarms etc might help, you could also use brief interventions called implementation intention interventions which are effectively goal setting and planning strategies (very easy, cheap and effective for the right patients). There are more, but more detail would be helpful in making more recommendations.

I agree with Amy. Non adherence can have many underlying causes and you need to know what it going on. A carefull assessment with your patient into the reason of non adherence is an important first step in resolving it. Depending on the outcome you can try to work out solutions together with your patient. This will not only give you valuable insight in the underlying problem, working together will most likely enhance your working alliance which often results in better adherence by itself. Is this expensive? It will take more of your time, and if time is money the answer is yes.

There are many reasons for non adherence. I would like to focus on the changing relationship between health professionals and patients. Health professionals do not have as much authority as a few decades ago, and they are not seen anymore by their patients as the most credible or only source of medical information. Therefore, to elicit a good reaction we need other ways of treating patients or clients, which we can find in approaches like Motivational Interviewing (MI) or Solution Focused Brief Therapy (SFBT). Both approaches take into account the fact that lots of people don't like being told what to do, even if it is in their best interest. People like even less being judged - health professionals might be more judgemental than they think they are. This sort of behavior by health professionals makes people look for excuses and not open for any other information you might want to give. MI and STSFT make behavioral changes possible, because those approaches have other assumptions about patients, or about the relationship a health professional has with a patient. In MI, an important assumption is "Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction" . In SFBT, the focus is on what a patient is already doing well to achieve his goals and this stimulates a 'can do' attitude with lots of advantages. In MI and in SFBT, the patiënt is not being told what to do, but being helped to make the decision to change and stick to it. She will be more active, taking responsibility and being more committed as well. We all make stories to make sense of the world, and by treating patients differently, you help change their stories of who they are, which we know is very effective (Timothy Wilson, Redirect, 2011). There are no tricks, just changing your behavior might yield good results - and a lot less frustration for the health professional! It is also a very cheap solutiuon which anyone can implement in any medical setting. We like behavioral changes in our patients and clients, but are we willing to change our behavior as well? (You can find lots of information online, I will add just a few links to short documents, the first on MI, the second on SFBT.)

http://www.stephenrollnick.com/index.php/all-commentary/64-what-is-motivational-interviewing http://www.0to10.net/sflong.pdf

Here’s what we do at a free clinic with lower socioeconomic indigenous groups in the tropical rainforest of Panama.

Change your mindset. How? For example, “compliance” and “adherence” are what good soldiers do when a superior officer gives them an order. That’s fine for single cause, single treatment short-term acute diseases but not for multivariate, comprehensive treatment, lifespan diseases.

What was our practical mission? For us, it was to decrease the frequency of the same repeated visits for complaints that could easily be handled in their own communities and adherence to effective treatment for infectious diseases.

What did we do? For example, if I saw a mother in the waiting room with several young well-behaved children, I personally recruited her, with great courtesy and respect, to accept to be a trained healthcare volunteer who would work directly within the community. In this indigenous population, informed and knowledgeable women who help the community are held in high esteem and respect. It was clear that among them such a woman would be far more persuasive than a male clinician like myself, or anyone who was not indigenous.

For colds, head lice, diarrhea, minor cuts and injuries, these became the contact persons who functioned as a triage and urgent care nurse in the community and, saved people lots of scarce money. They not only were trained on the essential medicines to provide, but were given the leeway to provide advice and folk remedies and rituals that the doctors at the clinic sanctioned as non-toxic and probably useful even as a persuasive placebo effect. We kept the relationships with these natural healthcare agents not at all money based. Instead, we gave them the right – with a great show of respect by the medical director – to be first in line for kids’ shoes, crayons, pencils, backpacks and other things when we had them to give out, to screen people for cataract surgery or “refer” a patient to the doctors for treatment, and to get “consults” directly from the physicians after all patients had been seen, which added further to these ladies’ prestige and effectiveness and – our mission – to adherence to effective treatment.

Outcomes? Adherence improved significantly and repeat cases dropped significantly. More important for the clinic was that the frequency of trivial medical consults dropped noticeably, freeing up physicians and PAs for the more serious cases. Because these “urgent care” ladies were right in the community and knew everyone on personally, her mere presence reinforced adherence, effective treatment, decreased use of limited resources and overall “client satisfaction” with the clinic right in the community where positive word-of-mouth produced an overall improved state of community. All at a cost of pennies because our mindset was to “Make do with what you’ve got,” rather than to the clinic because the essential medicines would have been used anyway had it been necessary for patients to come all the way to the clinic.

Recommendations: (1) get away from our First World assumptions, (2) learn to think poor, and (3) make do with you got.

Dr. Henry Franceschi