Medication adherence: Social and behavioral factors (internal)

Disease progression is a consequence of poor medication adherence. Statistics show that chronic illness affects over 130 million Americans, and that only 25% to 30% of medications taken correctly. 

Six major “buckets” impacting medication adherence have been identified by RxLive following scientific literature review — cost; side effects; skills; understanding and knowledge; social and behavioral factors; and access to care and burden of regimen. 

Several internal and external factors comprise the social and behavioral bucket that can be addressed by pharmacists with the aid of intervention suggestions available on the RxLive platform — lack of motivation; lifestyle; negative beliefs pertaining to the treatment and monitoring plan, healthcare system or diagnosis; challenges with provider-patient relationships; social and family support; psychological problems. 

As we continue our series examining medication adherence, this is the first part of a two-part blog examining how social and behavioral factors can affect medication adherence. This post covers internal motivators. 

A patient’s unique combination of social and behavioral factors

Internal factors affecting a patient’s medication adherence are intrinsic to each individual and, depending on their combination, can have a dramatic impact on their adherence. Factors can include a lack of motivation, poor lifestyle choices, and negative beliefs regarding treatment and monitoring plans, the healthcare system, or a diagnosis.

Motivation is a highly variable factor, affecting behaviors related to health-related activities that typically aren’t considered enjoyable, such as regular exercise or better nutrition. Lack of motivation can surface from multiple sources such as a symptom of an illness, feeling overwhelmed, activity level, difficulty coping, or unmet psychological needs. The Self-Determination Theory (SDT) of motivation posits that three basic psychological are needed for motivation: autonomy, competence and relatedness.

Limiting lifestyle choices such as smoking, substance abuse, maintaining a healthy diet and exercise regimen and other options certainly can affect adherence, the number of medications required, and a patient’s adherence to their medication regimen. First, we know that some lifestyle behaviors can be addictive and not easily overcome. We first think of smoking, drugs or alcohol. But the same can be true of foods that we know aren’t good for us, containing too many fats, sugars or other carbs. (Remember the potato chip commercial that said “No one can eat just one”? It’s pretty much true, isn’t it?) Not only can foods have a negative impact on our BMI, blood sugar and health effects, they can also interact with medications, causing adverse effects or absorption interference.

In addition, some medication regimens can be difficult to maintain within a patient’s already stressful and complex lifestyle — for instance, 2 doses/day for some meds and 3/day for others — as they juggle work, commute, family responsibilities and more. Thus, it can be far too easy to miss or mis-time doses or even cease them entirely due to lack of time to get refills before recommended by their physician.

Negative beliefs about a treatment and monitoring plan, the healthcare system or a diagnosis can coexist or independently affect a patient’s medication adherence. A study published in The Journal of the American Board of Family Medicine reported that 52% of the 343 surveyed held negative beliefs about medications and were 49% less likely to adhere to medication regimens than those with positive beliefs on their safety and health value. Negative beliefs about medications include the fear of side effects or addiction, preferences, perceived harm vs. benefits, fear of monitoring capabilities, and faith in the medications. 

Additionally, erosion of patient trust in the healthcare system occurs from historical events, stigma perceptions, present biases, and negative media coverage. According to Gallup polls, 70% of Americans view the U.S. healthcare system as having significant problems, including being dangerously disjointed between one provider organization and another. This lack of trust in institutions and the health system in general leads to lack of trust in clinical recommendations, including medications. 

In addition, negative beliefs about a disease state — from sheer denial to anger or hopelessness — can definitely affect how well patients adheres to their medication regimen. If they deny the very existence of leukemia, for existence, they won’t believe (and thus adhere to) that the prescribed medication has value in optimizing their health.

Pharmacists can play a critical role here through motivational interviewing (MI) within medication therapy management (MTM) programs and repetitive counseling sessions. MI is a patient-centered tactic to stimulate internal motivation for behavior changes, based on partnership, acceptance, compassion, and evocation of patients’ strengths. 

How pharmacists can improve medication adherence regarding internal social and behavioral factors

Controlled motivation — spurring patient action through pressures, awards, punishments, avoidance of disapproval, or guilt — isn’t a lasting form of motivation. Instead, create a blame-free environment that doesn’t force the patient to do something they are reluctant if not unwilling to do. What’s been proven effective is to use the guided principles of RULE: 

  • Resist the urge to point out the patient’s problems
  • Understand the patient motivations
  • Listen actively and empathetically
  • Empower the patient to improve their health through skill-building and overcoming barriers

A study conducted by Evolve Pharmacy Solutions showed a 5% to 9% increase in medication adherence rates with a MTM program that incorporates motivational interviewing. MI techniques should extract patients’ future life goals, which inherently generates motivation and excitement. The pharmacist can then show patients how the medication can help them reach those goals, thus shifting their behavior, attitudes, beliefs and motivation towards adhering to their medication regimen. Our goal here is to enable patients establish reasonable goals that are achievable; then, in follow-up conversations, our pharmacist can acknowledge and reinforce the patient’s accomplishments to further build confidence and reinforce continued improvements. 

Lack of motivation — Aligned with The Self-Determination Theory of motivation, pharmacists can increase internal motivation by developing autonomy, competence and relatedness. MI aligned with SDT emphasizes the responsibility and value of patient involvement in their healthcare decision-making, growing their internal motivation to improve adherence. Here, we assess patients’ readiness to change, evaluating their personal motivations, what drives their individual behaviors, and motivational gaps. 

Pharmacists should provide meaningful information and rational support for change that allows the patient to autonomously determine the importance of their medication regimen, aligning their thoughts with the central values presented. Additionally, during MI, pharmacists can increase motivation by building patient confidence and competence via relatedness. Through the teach-back method and repetitive counseling sessions, pharmacists can instill patient confidence and competence in administration techniques or other teachable components of their regimen. 

Further, the level of relatedness patients experience with their healthcare provider affects the likelihood of adhering to recommendations by facilitating an internal behavior change. Impart respect and empathy to gain the trust in patients who may be in a situation outside of their familiarity or technical zones of comfort. Pharmacists are recognized as some as some of the most trusted in the healthcare chain, having a strong opportunity to assist patients building autonomy and competence through relatedness and MI to increase their intrinsic motivation for better medication adherence. 

Limiting lifestyle factors: Through patient counseling using MI, explore and emphasize patients’ long-term goals that can be realized through medication adherence and improved lifestyles. Work in unison with patients to create achievable courses of action to improve diet, increase exercise, cease smoking or substance abuse, eliminate triggers, and reduce stress. Reflectively listen, guiding patients to generate their own solutions. The pharmacist can provide recommendations for alternative support groups, healthcare professionals, or cognitive behavioral therapy (CBT) that can assist in recovery or improvement in certain health-related lifestyle areas. In cases of addictive lifestyle behaviors, the pharmacist should notify the provider and cooperatively create strategies to help the patient overcome their barriers and promote adherence.

Negative beliefs about the treatment and monitoring plan, healthcare system, or diagnosis — Allow patients to identify and transform their negative beliefs through empathetic listening and MI. Discuss current beliefs, uncovering why negative views exist. Offer knowledge-based professional reasoning on how the medications work to thwart disease progression, discuss self-monitoring techniques or alternatives, and dispel fears about addiction, side effects, or lack of faith in mediations. Identify positive experiences patients have had in the healthcare system and point to research, innovations, patient choice and empowerment, rapid access, and positive statistics to build confidence and trust in the system. Motivate patients to find hope and support for their illness through family, physician, pharmacist and social groups, offering recommendations to support groups and programs.

Summary

Internal social and behavioral factors can have a profound effect on medication adherence and vary significantly between patients. Pharmacist-directed motivational interviewing during repetitive counseling sessions is an impactful strategy to instill positive health-related behaviors, as performed by RxLive clinical pharmacists. 

Related blogs

References

Facilitating Health Behavior Change and Its Maintenance: Interventions Based on Self-Determination Theory. EHPS

Motivational Interviewing for Medication Adherence. American Pharmacists Association

Patient Beliefs Have a Greater Impact Than Barriers on Medication Adherence in a Community Health Center. JAMA

Pharmacies: Improving Health, Reducing Costs. National Association of Chain Drug StoresSeven in 10 Maintain Negative View of U.S. Healthcare System. Gallup

Author avatar
Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.