Current Directions in Psychological Science
http://cdp.sagepub.com/ Patient Adherence With Medical Treatment Regimens: An Interactive Approach
Alan J. Christensen and Jamie A. Johnson Current Directions in Psychological Science 2002 11: 94 DOI: 10.1111/1467-8721.00176 The online version of this article can be found at: http://cdp.sagepub.com/content/11/3/94
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VOLUME 11, NUMBER 3, JUNE 2002
Patient Adherence With Medical Treatment Regimens: An Interactive Approach
Alan J. Christensen1 and Jamie A. Johnson
Department of Psychology, The University of Iowa, Iowa City, Iowa
Abstract Inadequate patient adherence to treatment regimens is a ubiquitous problem in health care and carries a profound personal, societal, and economic cost. This article illustrates a general theoretical framework we believe to be useful for the interpretation, conception, and design of adherence research. The core tenet of this framework is that factors that influence adherence can be better understood by considering the interactive effects of patients characteristics, type of adherence intervention, and characteristics of the illness and medical treatment context. This framework represents an extension and application of previous theory and research from personality, social, and clinical psychology concerning the value of an interactionalist perspective. We illustrate the framework using some of our past work involving treatment adherence among patients with chronic renal failure. Keywords patient adherence; interactive framework; personality; aptitude-treatment interaction
Over the past several decades, the potential ability of medical professionals to diagnose and treat physical disorders has been propelled by an exponential increase
in biomedical knowledge and new technologies. Ironically, the potential effectiveness of these advances continues to be challenged by a most fundamental requirement, behavior change on the part of the patient. Whether medical intervention requires a patient to follow a prescribed medication regimen, involves making a necessary dietary or other lifestyle change, or simply requires an individual to attend a scheduled appointment or procedure, the patients adherence is, in virtually all cases, a necessary condition for safe, effective, and efficient treatment. Inadequate patient adherence is a pervasive problem and one that carries a profound personal, societal, and economic cost. Although estimates of patient nonadherence vary across regimens, settings, and populations, the available data suggest that between 20 and 80% of patients do not adhere to the basic requirements of their medical treatment regimen (Dunbar-Jacob & Schlenk, 2001). For example, in a study involving patients with longstanding, serious hypertension, electronic monitoring suggested that 61% of these patients failed to take their antihypertensive medications as prescribed (Lee et al., 1996). The rate of nonadherence appears to be highest for preventive regimens in asymptomatic patients, slightly lower for chronic regimens in symptomatic populations, and lowest for time-limited regimens in acutely ill patients. Estimates of the economic costs of nonadherence range from $25 billion annually in additional treat-
ment costs and hospital admissions to more than $100 billion a year when lost productivity and total economic impact are considered (Berg, Dischler, Wagner, Raia, & Palmer-Shevlin, 1993). Patient nonadherence has been linked to increased sickness, treatment failures, and hospitalization, and to higher mortality across many clinical populations. Among patients being medically treated for hypertension, for example, the risk of being hospitalized or dying from coronary heart disease is 4 times greater for individuals who fail to continue to take antihypertensive medications as prescribed than for individuals who comply with their medication regimen (Psaty, Koepsell, Wagner, LoGerfo, & Inui, 1990). It is believed that as many as 75% of renal transplant failures in the second year following transplant may be due to nonadherence with the immunosuppressive medication regimen (Kiley, Lam, & Pollak, 1993). An increasing concern in the treatment of HIV and AIDS is the recognition that patients lack of adherence with antiretroviral regimens is resulting in virus mutations that are increasingly resistant to drug therapy (Catz & Kelly, 2001). Similar concerns have arisen with regard to bacterial infections, as many antibiotics are becoming less effective at fighting common bacteria such as streptococcus and tuberculin.
DETERMINANTS OF ADHERENCE: AN INTERACTIVE VIEW Given the prevalence and consequences of patient nonadherence, it is not surprising that considerable attention has been devoted to identifying patients characteristics that are associated with nonadherence, as well as to designing and implementing intervention strategies that
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might facilitate adherence. Despite considerable resources being devoted to these two issues, the collective empirical progress of this work has been modest at best. For example, comprehensive reviews of the adherence literature have generally concluded that there is little or no predictable or consistent association between patients characteristics (i.e., personality traits, expectancies or beliefs, sociodemographic factors) and adherence to treatment (e.g., Dunbar-Jacob & Schlenk, 2001). Over the past several years, we have worked with our colleagues to formulate an alternative interpretation to explain the lack of progress and marked inconsistency in this area of adherence research (Christensen, 2000). Specifically, we have proposed that the associations between patients characteristics and adherence may vary predictably with features of the disease context or treatment regimen (i.e., that the person-context interaction needs to be considered). From this perspective, a lack of consistency across heterogeneous treatment settings and populations may simply reflect expected behavioral patterns arising from the interaction between individuals characteristics and the medical treatment or illness context. To explore this possibility, an interactive approach is necessary (see Fig. 1). The basic assumption in this perspective is that relevant contextual or treatment-related features should be assessed explicitly, and that the interaction of these factors with patient variables should be tested directly. At a general level, this personby-context interactive framework has a long history in the science of psychology. According to the interactionalist perspective in personality and social psychology, attempts to identify personality traits that predict behavior are of limited usefulness unless one also considers the context an individual is facing
Fig. 1. Conceptual representation of the patient-by-treatment-context interactive framework. The dashed lines reflect the fact that research generally does not find that patient characteristics or contextual features have a significant effect on adherence. Adapted from Christensen (2000).
(Higgins, 1990). From this perspective, it is the interactive effect of person factors and contextual factors that most strongly influences behavior. Within clinical psychology, the interactionalist perspective has been apparent in the research on the outcome of psychotherapy (Dance & Neufeld, 1988). In this literature, studies that have adopted an interactive perspective (often referred to as aptitude-treatment interaction studies) consider the possibility that a given intervention strategy may be more effective for certain subgroups of patients than for others. This approach serves as an alternative to the common practice of treating all patients with a given disorder or target problem as a homogeneous group, ignoring potential differences among them. One of the more consistent patterns that has emerged from studies adopting an interactive framework is that individuals with more active and internally focused coping styles show a better response to treatments that emphasize selfcontrol than to treatments that emphasize therapist control (Dance & Neufeld, 1988). Our research groups studies involving patients with end-stage re-
nal disease (ESRD) illustrate the potential value of the interactive framework in understanding influences on adherence behavior (e.g., Christensen, 2000; Christensen, Smith, Turner, & Cundick, 1994; Christensen, Smith, Turner, Holman, & Gregory, 1990). The large majority of patients with ESRD face the prospect of lifelong medical treatment with a form of renal dialysis. In addition to undergoing frequent and time-consuming dialysis sessions, these patients are required to adhere to a multifaceted behavioral regimen that includes making substantial dietary changes, following strict fluid-intake restrictions, and taking one or more medications on a regular basis. Our past work has suggested that adherence is best when the patients characteristic or preferred style of coping is consistent with the contextual features or behavioral demands of the particular type of dialysis treatment the patient is undergoing. For example, patients with highly active or vigilant styles or coping preferences exhibit better adherence when undergoing a form of dialysis that is primarily patient controlled and carried out at home, whereas patients with a less active style or a
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96 tendency to disengage from stressful situations show better adherence when undergoing staff-administered dialysis in a hospital or clinic. Thus, it is the degree of congruence between the patients coping style and the behavioral requirements or constraints of the medical treatment context that appears important. Because the vast majority of past adherence studies have examined only the main effects of a given patient characteristic, they have been unable to detect potential effects of the person-context interaction.
VOLUME 11, NUMBER 3, JUNE 2002
ENHANCING PATIENT ADHERENCE: APPLYING THE INTERACTIVE FRAMEWORK In the most comprehensive review to date, Roter et al. (1998) examined the results reported in 153 studies that investigated a variety of behavioral (e.g., reinforcement of adherent behavior), psychoeducational (e.g., instruction in the reasons the treatment regimen is necessary), and affective-based (e.g., help managing emotional distress that may undermine adherence intervention strategies) intervention strategies designed to promote patients adherence to their treatment regimens. These studies involved more than 20 different medical conditions and treatment regimens. The central conclusion of this quantitative review was that various interventions had a weak to modest, but significant effect on indicators of patient adherence, but that no single intervention strategy appeared consistently stronger than any other. There was some indication that interventions combining cognitive, behavioral, and affective components may be more effective than single-focus interventions. Perhaps not surprisingly, the conclusion that different approaches
to facilitating adherence have essentially equivalent effectiveness mirrors the typical conclusion of research on the outcomes of psychotherapydifferent treatments have equivalent efficacy. However, it is important to note that virtually none of the adherence-related studies to date have considered the possibility that the efficacy of a given intervention approach varies across subgroups of patients. We believe that the patient-context interactive framework is useful for identifying potential moderators of intervention success. For example, findings from the broader psychotherapy-outcome literature, as well as from our own adherence research, suggest that self-control-based strategies (e.g., self-monitoring, selfevaluation, and self-reinforcement of adherence behavior) may be particularly effective in enhancing adherence among patients who characteristically have active styles of coping with illness or treatmentrelated issues. In contrast, a more structured intervention or one that features more control by the treatment provider (e.g., behavioral contracting, external inducements, instruction by the provider) may benefit patients with more passive styles. Other characterizations of individual differences are also conceptually relevant and may be important to consider. One possibly useful framework is the Five Factor Model of personality. From the perspective of this model, variability in personality traits can be distilled to five underlying dimensions: neuroticism (reflecting generalized emotional distress or chronic negative affect), extraversion (reflecting sociability, assertiveness, and cheerfulness), openness to experience (reflecting imaginativeness, intellectual curiosity, and unconventionality), agreeableness (reflecting altruism, trust of other peoples intentions, and cooperativeness), and consci-
entiousness (reflecting self-discipline or self-control, dependability, and will to achieve). The potential importance of the Five Factor Model of personality as an organizing framework for patient assessment has been highlighted in both the adherence (Wiebe & Christensen, 1996) and the psychotherapy (Anderson, 1998) literatures. For example, patients high on the agreeableness trait may respond better to group-based interventions or interpersonally oriented strategies for promoting adherence, whereas those low on this trait may benefit from an individualized, less confrontive approach. Each of these general intervention approaches has been previously investigated by adherence researchers but has not yet been considered within an interactive framework.
MOVING FORWARD: CHALLENGES AND RECOMMENDATIONS FOR FUTURE RESEARCH Rather than attempting to review and critique the large literature on patient adherence, we have illustrated a general theoretical framework we believe will be useful for the conception and design of future adherence studies. Adoption of an interactive approach encourages adherence researchers to do two things. First, it encourages them to systematically consider aspects of the illness and medical treatment context that are potentially relevant to behavioral or psychological processes. Although much of our work has focused on the contextual issue of how much patient control a treatment offers, many other aspects of the illness or treatment context may be important to consider. In our own work, we have found that existing data and theory from the broader literature on the effects of stress (e.g.,
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work on urban or environmental stress; Glass & Singer, 1972) can provide very useful direction in this regard. That is, relevant characteristics of the illness and medical treatment context generally parallel factors that have been identified in the broader literature as being moderators of the effects of stress (e.g., controllability of treatment delivery, predictability of treatment response). Second, the interactive framework encourages researchers to consider the possibility that the utility of a given intervention may vary across different diseases or treatment settings. Thus, we believe this framework will prove useful in the design, implementation, and testing of intervention strategies. For example, patients facing diseases or treatments that allow them a substantial degree of control over their own treatment delivery (e.g., diabetes management) seem more likely to benefit from interventions promoting selfmanagement, whereas patients whose illness and treatments allow them less control (e.g., most forms of cancer) may benefit from less instrumental, more emotion-focused intervention strategies. Perhaps more than any other issue in our increasingly interdisciplinary science, the problem of patient adherence clearly falls at the intersection of physical health and behavior. We hope that the framework and ideas presented here prove useful to researchers and providers addressing this most
vexing problem. As medical technologies continue to expand, so too will the opportunities for psychological science and practice to play a pivotal role in determining the effectiveness of these technologies. Ultimately, human behavior is likely to remain the sine qua non of health care delivery for many years to come. Recommended Reading
Christensen, A.J. (2000). (See References) Dance, K.A., & Neufeld, R.W.J. (1988). (See References) Roter, D.L., Hall, J.A., Merisca, R., Nordstrom, B., Cretin, D., & Svarstad, B. (1998). (See References) Wiebe, J.S., & Christensen, A.J. (1996). (See References)
AcknowledgmentsPreparation of this manuscript was supported in part by National Institute of Diabetes and Digestive and Kidney Diseases Grant DK49129 awarded to Alan Christensen.
Note
1. Address correspondence to A.J. Christensen, Department of Psychology, E11 Seashore Hall, The University of Iowa, Iowa City, IA 52242; e-mail: [email protected].
References
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