In developed countries, adherence among patients suffering chronic diseases averages only 50%, while in developing countries, the rates are even lower. [1]

Strengthening adherence to prescribed therapies has the potential to significantly improve patient outcomes and reduce demand for healthcare, but there is a need for greater understanding and more research on this issue. With the pandemic putting further pressure on healthcare systems, there is an opportunity to reduce some of this strain by giving adherence more attention, and to take advantage of the wider use of digital healthcare solutions, triggered by the pandemic restrictions.

Understanding adherence
Non-adherence generally falls into two categories. In the first instance, the patient intentionally decides not to follow treatment recommendations. In the second, unintentional non-adherence occurs, meaning that the patient wants to follow the agreed treatment but is prevented from doing so by barriers that are beyond their control. [2] One of the reasons why addressing non-adherence is so challenging is that there may be multiple contributing factors, such as social and economic circumstances, the selected therapy, or patient lifestyle. Patients may also have certain beliefs or preferences that influence their motivation to start and continue with treatment. For instance, patients are often particularly reluctant to discuss gastroenterological concerns, and so they may feel embarrassed or uncomfortable about their prescribed treatment. In sum, healthcare professionals (HCPs) will need to endeavour to understand an individual’s specific circumstances to be able to devise a solution, and research has shown that individually tailored interventions are likely to be effective at changing behaviour. [3] 

Educational and behavioural interventions
Rather than simply telling patients what their treatment plan is, it is valuable to take the time to explain the decision-making process to patients, so that they feel a sense of ownership of their treatment. This discussion could cover:

• the benefits and adverse effects of available therapies or medical devices
• a review of the alternatives to the treatment or device that is finally chosen
• the rationale for the selected treatment (improve symptoms, encourage weight gain, etc.)
• the need for prolonged treatment
• the expected effects (e.g., speed of onset) and side effects
• any possible adjustments that might be needed during treatment. 

Knowing what to expect, from benefits to side effects, can boost patient motivation to persevere with their treatment. However, education alone may not be sufficient. To facilitate adherence, patients must be able to fit treatment into their daily routine, with minimal disruption. HCPs should therefore check in with patients about when they will be administering their treatment or using their device, and how they are planning to set reminders. Deciding on a routine during an appointment will increase the likelihood of adherence, while also giving patients some peace of mind and confidence in their ability to stick to the treatment programme. It is recommended that patients keep a treatment diary to track medication administration or device use, as well as symptoms; this can also have a motivating effect.

Reviewing progress
To help maintain patient perseverance, it is critical to schedule follow-up appointments after initial advice and prescription. The timing of these follow-ups is important; the standard 12-week follow-up appointment may be too late, as patients starting a new treatment plan benefit from check-ins within the first few weeks. They can then report back on their experience, allowing HCPs to intervene as needed, and advise on changes in dosage or treatment routine. This dialogue makes patients feel supported, and that their personal needs are being taken into consideration. It may be more efficient to check in with patients through teleconsultations, as regular face-to-face appointments can increase costs, as well as the burden on patients. Patients may also benefit from exchanging experiences with others in a similar position, through community and patient groups.

This ongoing support, as well as tailored treatment plans and progression, serve to make patients feel actively involved in their treatment, rather than simply passive recipients of advice. Greater investment of time and resource in supporting patients to keep going with their treatment can only help to strengthen understanding of adherence approaches in the long-term, so that healthcare systems can begin to see improved adherence figures.

Further useful information can be found in the Bowel Interest Group’s report on the ‘Importance of Adherence’: https://bowelinterestgroup.co.uk/resources/importance-of-adherence/

Case study

A patient suffering from progressive Multiple Sclerosis (MS) embarked on transanal irrigation (TAI). Despite high expectations of the treatment, getting used to the therapy took a little while. TAI is used to treat bowel dysfunction, including faecal incontinence and constipation, where physical exercises, dietary changes and/or medication alone are insufficient. 

Firstly, training and moral support, initially in person from a nurse and then from a telehealth specialist who provided on-going support, enabled the patient to gradually fine-tune their treatment. For instance, with guidance during the early months, they experimented with different water volumes to establish the optimum level for effective bowel emptying. ‘Special routines’ were also established to maximise comfort and peace of mind before, for example, going on holiday or taking a flight. 

All this training and support helped the patient’s confidence as routines were optimised and ensured long-term adherence. The patient emphasised the critical need for such support during the early period and describes the therapy as ‘utterly life changing’.

The Bowel Interest Group

The Bowel Interest Group (BIG) is a multi-disciplinary group dedicated to raising the profile of bowel management. The group provides evidence-driven educational resources to support healthcare professionals treating patients with bowel conditions. Explore BIG resources, webinars and news here: https://bowelinterestgroup.co.uk/

Dr Benjamin Disney, Consultant Gastroenterologist, University Hospitals Coventry and Warwickshire NHS Trust

References

1. Sabaté, E., 2003. Adherence to long-term therapies: Evidence for action. World Health Organisation. [online] Available at: https://www.who.int/chp/knowledge/publications/adherence_full_report.pdf?ua=1.
2. National Institute for Health and Care Excellence (NICE) (2009) Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence. CG76.
   Available at: https://www.nice.org.uk/guidance/cg76 .
3. Garfield, S., Judah, G., 2021 Learning from successes: designing medication adherence intervention research so that we can learn what works and why. BMJ Quality & Safety. Available at: https://qualitysafety.bmj.com/content/early/2021/07/11/bmjqs-2021-013381#ref-14