In the context of medical treatment, the term adherence refers to a patient’s success in following the recommendations of a health care provider for disease prevention and treatment. Nonadherence (also called noncompliance) refers to a patient’s failure to follow these recommendations, such as by not filling a medication prescription or by stopping the medication before being instructed to do so, improperly using a medical device, carrying out prescribed behaviors (e.g., specific exercises) incorrectly, or entirely ignoring medical advice (such as to avoid certain foods, or to engage in disease screening). Nonadherence can be purposeful or not. The term “unintentional nonadherence” is used to describe cases in which patients believe (mistakenly) that they are adhering to what has been prescribed, whereas “intentional nonadherence” is used for cases in which patients choose to disregard treatment recommendations completely or to modify their prescribed regimens.
Across a variety of disease conditions, 25% of patients (on average) do not adhere to prevention and disease management activities (including taking medications, going to medical appointments, obtaining screening, exercising, and/or dieting); for some medical conditions, adherence can be as poor as 50% or less. Adherence is a behavior that is strongly connected to health outcomes. On average, the odds of a good health outcome for patients who are adherent are 2.88 times higher than for nonadherent patients. Nonadherence can take a significant toll not only on patient health outcomes but also on providers and the health care system. At the interpersonal level, the inability to achieve health care goals due to nonadherence can be frustrating for both patients and their providers, and from a societal standpoint, nonadherence produces a significant economic burden (between $290 and $300 billion annually in the United States alone). In addition, the number of medical visits wasted annually in the United States as a result of nonadherence is estimated to be at least 240 million.
According to the World Health Organization, adherence is affected by many factors such as: (1) the health care system including the provider–patient relationship, (2) the patient’s disease type and severity, (3) the type of treatment regimen and its complexity, (4) patient characteristics, and (5) socioeconomic factors. This chapter will focus on the interplay of these factors in understanding the role of the provider–patient relationship and communication quality in effective methods for promoting adherence and chronic disease management among all, including the most vulnerable, patients. These include patients of ethnic minority status, low socioeconomic standing, low education level, and/or low health literacy. Emphasis will be placed on targeting individual patients’ needs to promote adherence through the use of a recently devised heuristic model offered by DiMatteo and colleagues, called the Information–Motivation–Strategy Model©.
OVERVIEW OF THE INFORMATION–MOTIVATION–STRATEGY MODEL©
Although the elements of the Information–Motivation–Strategy Model© (IMS Model) were first introduced in the early 1980s, there was insufficient empirical research on which to build support; ...