For many practitioners, ensuring that patients are adherent to their treatment is a primary concern. You can provide a well-researched and comprehensive treatment plan, but how do you ensure that a patient follows your recommendations? In the past year, our Integrative Medical Advisory and Insights teams have researched this subject heavily to identify the primary barriers to adherence for patients as well as the key strategies Fullscript practitioners use to overcome these barriers.
In this article, we will examine the concept of adherence and discuss the top barriers identified by Fullscript practitioners.
What is patient adherence?
Adherence can be defined as the extent to which a patient’s behaviors follow an agreed-upon prescription or therapeutic regimen. (1)(2)(3) It is similar to “compliance”; however, adherence takes further consideration of the patient’s views and choices, and it allows them to play a more active role in the development of the treatment plan.
Generally, treatment adherence rates decline for all patients over time, and the likelihood of this is influenced by many different factors, such as practitioner and patient education, cost, feasibility, and patient readiness to change. (13)
Factors that influence adherence
There are several hundred possible factors that may affect the likelihood of a patient properly following their treatment plan. The World Health Organization’s (WHO) 2003 report on adherence describes five interacting dimensions that influence adherence to treatment plans within states of chronic disease, which include condition/disease, patient, social and economic, systemic and healthcare team, and therapeutic factors. (3)
A summary of the factors that may influence adherence is provided below.
- Development course or state of the condition
- Existence of treatments available
- Extent of physical, psychological, social, educational, or employment disability
- Presence of comorbidities
- Symptom severity
- Level of motivation, self-efficacy, or knowledge of the disease and therapy
- (Mis)understanding of the disease, diagnosis, or therapeutic protocol
- Negative feelings like stress, hopelessness, or anxiety towards the treatment or condition
- Perception of therapeutic expectations, effects, efficacy, or need for treatment
Social and economic factors
- Age, race, and gender
- Culture or social beliefs of the treatment or disease
- Literacy level and education
- Living location and transportation access
- Poverty or employment status
- Social and family support
- Treatment cost
Systemic and healthcare team factors
- Access to treatment
- Availability or scope of care/coverage
- Establishment of community support and self-management programs
- Patient-practitioner relationship
- Practitioner education, workloads, incentives, and feedback
- Systemic patient education
- Time constraints, follow-ups
- Availability of medical support for side effects
- Frequency of treatment adjustments
- Presence of adverse effects
- Protocol complexity
- Speed of therapeutic benefits
- Therapy duration
- (Un)success of treatment adjustments
Despite the many contributing factors, non-adherence has been traditionally considered a patient-centered problem. Therefore, interventions to improve adherence have primarily focused on patient factors and have largely ignored the other dimensions. (9)(10)(16)(17)
It is also important to note that these factors have been primarily studied within the realm of conventional medicine or in the context of adherence to pharmaceutical medications. However, many of these factors are likely relevant to integrative treatment recommendations, including diet, physical activity, or complementary and alternative medicines such as supplements. (4)(5)(6)(7)(8)(11)(12)(14)(15)
Understanding adherence using Fullscript practitioner insights
To add to the body of knowledge on the topic of treatment adherence, we conducted a series of interviews and a survey of Fullscript practitioners with both high and low adherence rates. Our goal was to understand more about barriers to adherence and identify strategies that practitioners could use to improve adherence.
A total of 25 interviews were conducted with practitioners who had demonstrated either a high treatment adherence rate (TAR) or a low TAR using the Fullscript online dispensary platform. High TAR was defined as having more than 70% of patients order every supplement (called a “full fill rate”) from their first recommended treatment plan, while low TAR was defined as less than 45%. To qualify for an interview or survey, practitioners needed to fit the appropriate TAR threshold and be considered an active Fullscript user, which was defined as having more than five patient orders placed through Fullscript over the previous six weeks.
To expand on our interview findings, a survey was conducted to gather insights from a larger number of practitioners and confirm suspected themes arising from the interview process. A total of 185 survey responses were received from both high-TAR practitioners (n=21) and low-TAR practitioners (n=83). The remainder of respondents (n=81) fell between the 45 to 65% adherence range.
While it was not possible to draw formal conclusions on the significant differences between these groups due to the low sample from high-TAR practitioners, the results highlighted certain trends, including a number of significant barriers and strategies for improving adherence.
Top 3 barriers to patient adherence
While many factors can influence an individual’s likelihood to follow a prescribed therapeutic regimen, we have identified the top barriers to adherence experienced by Fullscript practitioners and their patients.
Our findings indicated that cost is the primary barrier to adherence, and it may be a difficult one to overcome. In integrative medicine, the cost of appointments and supplements is often not covered by private insurance plans, or patients choose to pay out of pocket. Due to the severity or chronicity of their health concerns, patients often end up engaging with numerous different practitioners to find solutions, which only further increases treatment costs.
Readiness to change
If a patient is not ready or committed to change, alterations to their diet and exercise routines or the idea of regularly taking dietary supplements may seem more challenging. Often, patients will come to appointments following a referral from a medical practitioner or at the urging of a partner or family member, but they are not yet convinced that it is the right move. If the patient does not feel that they are ready or need to make any changes, it compromises the likelihood of adherence from the very beginning.
Patients feeling overwhelmed with the treatment plan is another significant barrier to adherence. Treatment plans may contain a long list of supplements or many aspects of the treatment to follow at different times throughout the day. Practitioners commonly report that their patients express feelings of being overwhelmed, particularly during their first visit and when significant changes are proposed.
The bottom line
According to our survey data, over 75% of practitioners claim that encouraging patient adherence is a key mission within their practice. Through our research, the top barriers to adherence for patients were identified as cost, readiness to change, and feeling overwhelmed. Understanding and addressing these factors when building a treatment plan is an important consideration for improving patient adherence, satisfaction, and potentially clinical outcomes.
Stay tuned for additional content and insights, including key strategies to improve adherence, to be released from the Fullscript team in the near future!
- Abu-Janb, N., & Jaana, M. (2020). Facilitators and barriers to adherence to gluten-free diet among adults with celiac disease: A systematic review. Journal of Human Nutrition and Dietetics, 33(6), 786–810.
- Agarwal, R., Gupta, A., & Fendrick, A. M. (2018). Value-based insurance design improves medication adherence without an increase in total health care spending. Health Affairs, 37(7), 1057–1064.
- Agu, J. C., Hee-Jeon, Y., Steel, A., & Adams, J. (2019). A systematic review of traditional, complementary and alternative medicine use amongst ethnic minority populations: A focus upon prevalence, drivers, integrative use, health outcomes, referrals and use of information sources. Journal of Immigrant and Minority Health / Center for Minority Public Health, 21(5), 1137–1156.
- Desta, M., Kassie, B., Chanie, H., Mulugeta, H., Yirga, T., Temesgen, H., … & Merkeb, Y. (2019). Adherence of iron and folic acid supplementation and determinants among pregnant women in Ethiopia: A systematic review and meta-analysis. Reproductive Health, 16(1), 182.
- Ding, A., Patel, J., Patel, J., & Auyeung, V. (2018). Attitudes and beliefs that affect adherence to provider-based complementary and alternative medicine: A systematic review. European Journal of Integrative Medicine, 17, 92-101.
- Ennis, E. (2014). Complementary and alternative medicines (CAMs) and adherence to mental health medications. BMC Complementary and Alternative Medicine, 14, 93.
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- Kelly, S., Martin, S., Kuhn, I., Cowan, A., Brayne, C., & Lafortune, L. (2016). Barriers and facilitators to the uptake and maintenance of healthy behaviours by people at mid-life: A rapid systematic review. PloS One, 11(1), e0145074.
- Kleinsinger, F. (2010). Working with the noncompliant patient. The Permanente Journal, 14(1), 54–60.
- Kleinsinger, F. (2018). The unmet challenge of medication nonadherence. The Permanente Journal, 22, 18–033.
- Krousel-Wood, M. A., Muntner, P., Joyce, C. J., Islam, T., Stanley, E., Holt, E. W., … & Webber, L. S. (2010). Adverse effects of complementary and alternative medicine on antihypertensive medication adherence: Findings from the cohort study of medication adherence among older adults. Journal of the American Geriatrics Society, 58(1), 54–61.
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- Nagata, J. M., Gatti, L. R., & Barg, F. K. (2012). Social determinants of iron supplementation among women of reproductive age: A systematic review of qualitative data. Maternal & Child Nutrition, 8(1), 1–18.
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- Sabate, E. (2003). Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization. https://www.who.int/chp/knowledge/publications/adherence_full_report.pdf?ua=1