The challenge of promoting treatment adherence

Evidence-based health care may identify treatments that are potentially effective for groups of patients; however, these are fundamentally dependent on the patient’s behaviour to ensure the method of application. A major problem for many people living with chronic illness, including those with skin conditions, is that they are on a number of medications and they fail to utilise their treatment effectively; this may be due to a lack of knowledge, skill, confidence or motivation.

One example of the problem is illustrated by psoriasis, with research evidence of the problems of treatment adherence. A study by Richards et al. (1999) reported high levels of ‘non-compliance’ with treatment. Several factors are likely to contribute to this situation. Survey evidence of expectations of treatment highlights the high levels of dissatisfaction (Krueger et al., 2001; Richards et al., 2001; Psoriasis Association and Beresford, 2002), with many giving up their treatment. Such evidence conveys the need for more consistent education, but other studies highlight the time burden of treatment (Finlay and Coles, 1995). These findings are significant since patients’ treatment expectations may affect their adherence to therapy.

The reasons for poor treatment adherence are complex. The situation involves a consideration of patient beliefs and behaviour. This is now explored in more detail by examining the process by which the health professional engages with the patient during consultation when outlining the treatment plan.

The importance of the concordance process
Effective adherence to treatment requires more than a traditional expectation of compliance, namely doing what the health professional expects ‘should’ be done. If adherence is to be improved, the process must involve actively engaging with the person ‘based on a negotiation about medication between health care professional and patient that respects patients’ beliefs and wishes’ (Royal Pharmaceutical Society of Great Britain, 1997).

The concordance process requires that both the patient and health care professional participate to reach an agreement on the nature of the problem (illness) and the treatment plan; their agreement needs to draw on the experiences, beliefs and wishes of the patient to decide when, how and why to use medicines (Medicines Partnership, 2003). Both parties need to treat each other as partners and recognise each other’s knowledge skills to improve decision-making (Atkins and Ersser, 2008). Patients’ views are no less important when making decisions about what is suitable for the patient to ensure a match to their preferences and lifestyle. Through such a process of negotiation, it is more likely that there will be cooperation with and so adherence to the agreed plan. Therefore, some of the strategies for developing a negotiated approach may include the following elements:

• Listening to patient’s beliefs and expectations;
• Dealing sensitively with patient’s emotions and concerns;
• Helping patients to make informed choices;
• Giving explanations and rationales for treatment options;
• Negotiating outcomes of consultations that both the prescriber and patient are satisfied with;
• Giving clear instructions to patients about their medication;
• Checking the patient’s understanding and commitment to treatment.

As an example, treatment adherence problems are a common cause for apparent failure that feature in atopic eczema and this includes factors such as the patient or parental carer having a poor understanding of disease (Fischer, 1996). In this context, there may be a discussion about enhancing the parent’s capacity to avoid trigger factors, managing the child’s sleep disturbance or finding better ways of communicating with professionals regarding treatment. Related concordance concerns may include the parent’s ability to manage successfully topical applications such as emollients, antibiotic and steroid creams. Some studies have attempted to enhance concordance within a dermatology context, for example, with improved adherence to compression therapy for patients with venous leg ulcers (Brooks et al., 2004).

To ensure effective use of treatment, it is necessary to explore what the patient understands by their treatment regimen within the consultation, since it may reveal areas of confusion. Evidence suggests that problems of adherence stem more from a disbelief in their efficacy to use prescribed medication effectively than from disease activity or pain (Taal et al., 1993). Furthermore, common problems arise from the need to manage a number of medications and from trying to sequence topical applications effectively. Also, there can be a lack of understanding of the conditions under which ‘as required’ drugs can be used appropriately. Practitioners also need to explore expectations of treatments. Qualitative research evidence suggests that dermatology patients may not share precisely the same views with dermatology professionals about what criteria are important in judging effectiveness; as in the case of those living with psoriasis (Ersser et al., 2002). In addition, if a person expects their treatment to work quickly but in practice, the medication is effective only after sustained treatment over a number of weeks, such as coal tar or calcipotriol use in psoriasis, there is a high risk that such treatment may be abandoned prematurely. This may also apply to the situation in which the patient believes their medication is designed to help with one symptom when it is for another, such as in the case when topical steroids may be used with the intention of controlling eczema, but when infected, an antimicrobial agent would be required.


There is a need to give consideration therefore to the range of factors affecting both the patients or carers’ treatment choice (preference) and use in practice and to recognise the related educational opportunities. The following discussions will take place within the context of the health care consultation, to which we now turn.