Is it enough to think that we can simply “nudge” patients into adherence? While persuasive behavioral nudges have been shown to improve outcomes, they are not effective 100% of the time. The problem of adherence is more than a basic processing error in weighing the risks and rewards of taking certain options. And we must consider whether we are overfocused on applying solutions derived from a Western, educated, industrialized, rich, and democratic (WEIRD) mindset to a problem that is a complex interplay of identity, knowledge, ability, motivation, lived experience, and culture.
Nonadherence to treatment is a complex problem that continues to create tremendous costs to manufacturers, the health system, and patients’ lives, and there is no “silver bullet.” But there are ways to address this challenge. Read on to examine the range of barriers and facilitators of adherence and the key factors of a successful approach by looking through an empathetic, human-centered design lens, and an evidence-based, experimental behavioral science lens.
What Stands in the Way of Adherence, and What Are the Solutions?
Nonadherence is a multifaceted problem, and no shortage of investment has been made in addressing it. More than 7001 apps are currently available on the topic, and many utilize “nudges” such as timely reminders that can improve compliance. So why does the problem persist?
The solution is not simple. Barriers to adherence in patients taking aromatase inhibitors for 10 years after breast cancer treatment are not the same as those taking phosphate binders for end-stage renal disease. Essentially, every person is unique.
Accordingly, success depends on understanding the multitude of interconnected factors that might be at play for a specific person with a specific condition and systematically addressing those. This starts and ends with deeply understanding the human element. What does this mean? Let’s take a step-by-step approach.
First, we need to focus on who that “someone” is at the core. What are their values, personality traits, and identity? How do these impact how they feel about and behave around disease or treatment? Studies have demonstrated that cultural beliefs such as valuing traditional medicine and personality traits such as conscientiousness are associated with adherence.2,3 Personalizing interventions based on these factors is key—for example, acknowledging that treatment may be complementary to cultural or religious beliefs, and partnering with appropriate groups such as traditional medicine practitioners to shape effective communications and engagements and support adherence behaviors.
Second, look at the “do-ability” of adherence behaviors. What are we asking people to do? How easy is it and does our audience have, and believe they have, the ability to do it? For example, medication adherence is significantly impacted by one’s own belief in their ability to perform certain behaviors (self-efficacy).2 As a result, capability and knowledge-building initiatives such as patient education can help them stick with their treatment plan.4
Motivation based on beliefs, benefits, and experiences is the third factor to consider. What are the perceived benefits versus the drawbacks of adherence behaviors and the incentives and reinforcement supporting them? For example, patients who don’t see an immediate benefit may become demotivated and stop taking their medications.5 Motivational interviewing, an interpersonal approach to exploring and resolving ambivalence and working toward a goal, is one approach to addressing these types of beliefs as they come up and has been shown to improve adherence in various health conditions.6
The fourth element to consider is the environment—both physical and social. Social support has been explored in many studies—in one example, people with HIV who are nonadherent to their medications often lacked social support in various areas of their lives.7 Solutions fostering direct interpersonal encouragement from healthcare providers and wider, functional support from loved ones can be powerful.8
And finally, we must look at cues that can prompt adherence behaviors at the appropriate time and place. Pure forgetfulness is one of the most commonly cited reasons for nonadherence.5 A wide range of studies have demonstrated that timely reminders and other types of cues, such as linking medication taking to habitual behaviors, can be beneficial.4 It can be as simple as placing pill bottles next to the coffee machine as a morning reminder.
When embarking on efforts to improve adherence, it’s crucial to take the time to explore the realities across all dimensions just described and consider interventions that address the areas specific populations struggle with the most.
The Wider Ingredients of a Successful Approach
This holistic problem diagnosis and solution development is a critical ingredient, but not the only one. Success requires incorporating new thinking on more dynamic and nuanced forms of change. Let’s explore the additional principles of a more effective, empathetic approach to adherence.
Harnessing human-centered design: The cocreative, iterative, and empathetic lens of human-centered design is the perfect partner to the evidence-based, action-oriented lens of behavioral science. Bringing these disciplines together will lead to more relevant interventions with a greater chance of success. The best approaches complement literature reviews with deep audience research, getting immersed in daily contexts and understanding the “why” behind behavior, and cocreating solutions with stakeholders, such as patients, caregivers, and healthcare professionals. The richest ideas often come from those who will ultimately utilize them. By including these groups from the beginning, you can start building trust and advocacy early. Furthermore, the iterative design process—from understanding key insights to cocreative solution development, to piloting, testing, and measuring—is crucial to solving adherence in a tailored and scalable manner.
Think beyond the nudge: Simple behavioral economics-informed nudges (e.g., restructuring choice architecture, message framing) may move the needle but are often insufficient. The models of health psychology that these are often based on don’t always take into account the broader environmental and societal contexts. They are often built entirely on theory or not extensively studied across a diverse range of populations or health behaviors. Instead, we need to draw from a range of disciplines—from health psychology to sociology to implementation science. For example, is there a systemic issue around medication access that needs to be addressed through policy or financial support? Consider these types of solutions, and patients will be one step closer to improving their health.
Crystallizing behaviors: Taking the time to specify the behavior change is critical. We should focus not just on a broad behavior such as taking the medication as prescribed, but also outline where and when this is occurring, with whom, and how often. By identifying the detailed steps that make up a behavior (e.g., “patient locates pill bottle, person pours a glass of water, then he or she takes the pill”), we can focus insight gathering and solutions more clearly and support patients to make specific plans that they can follow.
Learning from past evidence: Many studies have been published around adherence (one meta-analysis found more than 1,100 peer-reviewed articles around adherence).2 Look at what was studied in the past, especially in the specific disease or patient population you are focused on. What models, drivers, and barriers of adherence have been studied? What psychologies are at play? What other interventions have been tested? A person who has a condition that is asymptomatic will have different attitudes and behaviors around treatment than someone whose disease has a tangible impact on daily life.2 Insights from past evidence can lead to better solutions to patient challenges.
Don’t stop at WEIRD: Equity should be a consideration every step of the way, from who you conduct research with to accessible solution design. Bring in diverse voices to insight generation, cocreation, and testing. Consider the audiences included in the evidence you have reviewed, and acknowledge that findings from WEIRD audiences aren’t guaranteed to translate broadly. If you don’t have insight or evidence from the people who should be benefiting from your work, make it a priority to learn, collaborate, and test with these groups.
Prediction and experimentation: Hypothesis generation and testing are core to the scientific method and thus to behavioral science. The above steps are likely to increase the chances of success, but until the solutions are tested, it’s hard to see the true impact on adherence for specific patient populations. Make predictions based on insights and evidence, test those predictions, and continue to refine, scale, and iterate solutions accordingly.
Adherence Can’t Just Be Nudged Away
There are no “silver bullets” as far as medication adherence is concerned. We do a disservice to patients if we assume we can simply nudge away the problem. Improving adherence requires critical evaluation of the available context-specific literature and a blend of deep, “below-the-surface” insight generation, human-centered design expertise, and behavioral science-driven guidance to move from understanding the problem to testing and iterating solutions.
The key to developing a successful model is to collaborate with behavioral scientists, researchers, and others with deep expertise in various disciplines and apply an interdisciplinary approach. Every patient is unique. Effective medication adherence programs should apply an empathetic lens. By doing this, our industry can make a massive impact on patient outcomes and on our health systems.
References:
1. Park JYE, et al. JMIR Mhealth Uhealth. 2019;7(1):e11919.
2. Shahin W, et al. Patient Prefer Adherence. 2019;13:1019-1035.
3. Ko KM, et al. Yonsei Med J. 2020;61(5):406-415.
4. Anderson LJ, et al. Am J Health-Syst Pharm. 2020;77(2):138-147.
5. Nelson LA, et al. Diabetes Res Clin Pract. 2018;142:374-384.
6. Papus M, et al. Patient Educ Counseling. 2022;105(11):3186-3203.
7. Enriquez M, et al. J Assoc Nurses AIDS Care. 2019;30(3):362-371.
8. Magrin ME, et al. Ann Behav Med. 2015;49(3):307–318.
