There is an old adage that medications work best when patients actually take them. Unfortunately, despite decades of efforts and expensive research, treatment adherence is the albatross of the pharma industry and still puzzling to payer and provider organizations, who are under intense pressure to meet quality goals while reducing costs.
Nearly 1 in 3 patients don’t fill their prescriptions and 3 in 4 don’t take them as prescribed.1 Non-adherence creates sub-optimal health outcomes and costs the U.S. healthcare industry more than $118 billion annually.2 It’s time to change the approach to the problem.
It’s About the Why
Pharma marketers know patients aren’t always adherent to their medications. They also know many patients don’t understand why it’s important to take medications as prescribed and that some, when they do admit to not taking their medication, give a multitude of reasons. Some patients decide not to take the medication at all, some miss a dose here or there, some take it on a schedule that works for them, and some take it only when they think they need it.
The healthcare industry spends lots of money to identify which patients are non-adherent, then push “interventions” like educational programs, games, hi-tech pill holders or email reminders to improve adherence. Ultimately, they’re puzzled when these solutions don’t work over the long haul.
In reality, this lack of long-term impact isn’t surprising. While many pharma marketers can probably indicate Who is non-adherent among their patient population, they can’t say Why those patients aren’t following their prescribed treatment. That is where they are missing the mark. It’s time to address the Why.
The Psychology of Non-adherence
A recent paper published in The European Health Psychologist3 provides fresh insight on how proven psychological models can be applied to understand why patients aren’t taking their medications. The findings represent a pivotal change in how pharma marketers might approach the design of adherence interventions and patient support programs.
The COM-B Model,4 first published in 2011, proposes that an individual’s behavior is influenced by many factors, all of which can be grouped into three components: Capability, Opportunity and Motivation. The authors of The European Health Psychology paper use the COM-B model to examine behaviors that drive treatment non-adherence.
As the literature reveals, non-adherence to treatment is a complex behavior, often fueled by a combination of factors. None of these factors work alone and some factors may evolve over time, impacted by age, circumstance and disease progression.
How do you uncover the Why? Research is clearly the first step but it’s a specific type of research driven by a health psychology perspective, not a statistical profile. The process is grounded in scientific rigor, with health psychologists applying evidence-based tools stemming from psychological theories and models to assess the patient population within a given disease state. These findings can then be applied to individuals to determine the specific motivators and barriers behind each patient’s non-adherence (the Why) so that targeted and effective interventions can then be designed to help improve adherence.
Importantly, this psychological framework is applicable across a wide range of diseases. Let’s look at patients on oral oncolytics. Studies have shown an average non-adherence rate of 21%5 in oncology patients taking oral medication, a fact that may be surprising given the seriousness of many cancers. Using the COM-B model, a qualified research team can start to identify specific beliefs that are driving non-adherent behaviors in this patient population.
Capability: Does the patient have the psychological and/or physical capability to do what’s being asked? Do they understand the disease and the selected treatment? Can they swallow a pill, open the cap and remember their medication times?
Opportunity: What are the external physical and social factors that enable or discourage adherent behavior? Can they afford their medication and do they have easy access to filling their prescription? Do they have issues with the taste, smell and size of the medication? Does social stigma or religious beliefs prevent patients from seeking out help or treatment?
Motivation: What is their perception of the seriousness of their illness and their belief about how helpful their treatment is? Do they believe it’s important to take their pill? Do side effects play a role in decreasing their motivation to take the prescribed dose? Are they depressed or anxious about their disease, their mortality, how their caregivers are supporting them (or not)?
These are just a few basic examples for each of the three categories. Individuals can have different reasons for non-adherence even if it’s the same type of non-adherence. For example, the belief that “I don’t think this pill is important,” can stem from different reasons such as, “I don’t think treatment is important right now” or “It’s just a pill, how important can it be?”
Adherence can also be influenced by the particular stage of the patient journey:
- A woman with a strong family history of breast cancer may be afraid to seek out a diagnosis or prophylactic treatment. Her motivation should be high, but fear and lack of social support might drive her away from medical care.
- A newly diagnosed breast cancer patient in a treatable stage of the disease can be very motivated and eager to manage their condition. They have a pink-ribbon brigade of support and want to cross the line to be a survivor, yet they are afraid of the rigor of treatment and side effects.
- Women with metastatic breast cancer can behave similarly to patients with chronic disease, as it relates to treatment adherence. They can become unmotivated, tired of long-term treatments and unsure of the outcome or treatment goal.
Why would pharma marketers invest in one-size-fits all communication tools when the reasons behind non-adherence are so different from patient to patient within the same disease, on the same medication?
Address the Why
Once we understand the Why, we are now able to create customized programs that address those unhelpful beliefs driving an individual patient’s behavior. Customizable doesn’t necessarily mean a personalized message for every single patient. Rather, it means allowing each patient to receive the right messages for them at the right time.
It could seem less costly in the short-term to send out the same messages worded the same way to everyone, but is that really the case? Current research suggests that targeting the interventions based on the reasons Why each patient is non-adherent will better empower each person to self-manage their disease, follow their prescribed treatment and improve their health outcomes.
1. “Take As Directed: A Prescription Not Followed [news release].” Alexandria, VA; National Community Pharmacists Association; December 15, 2006.
2. Forissier, T. and Firlik K. “Estimated Annual Pharmaceutical Revenue Loss Due to Medication Non-Adherence.” Capgemini Consulting; 2012.
3. Jackson, C.; Eliasson, L.; Barber, N. and Weinman J. “Applying COM-B to Medication Adherence.” The European Health Psychologist 2014, 16(1), 7-17.
4. Michie, S.; van Stralen, MM. and West, R. (2011). “The Behavior Change Wheel: A New Method for Characterizing and Designing Behaviour Change Interventions.” Implement Science, 6, 42. Doi:10.1186/1748-5908-6-42
5. DiMatteo, M.R. “Variations in Patients’ Adherence to Medical Recommendations: A Quantitative Review of 50 Years of Research.” Med Care, 2004. 42(3): p. 200-9.