Concept analysis of adherence

After literature review, four attributes of adherence that have been identified in the literature are self-efficacy, self-determination, autonomy, and relapse prevention.

Adherence is defined as achieving self-determination and autonomy characterized by self-efficacy promotion and relapse prevention.

Mary was a 68-year-old woman, who was diagnosed with diabetes and hypertension. She went to hospital due to high blood pressure. The nurse checked her blood pressure, and it was 179/94 mmHg. Mary met with a doctor, Tom, and discussed options. Doctor Tom and Mary agreed that she should take a blood pressure medication to control the hypertension. In addition, some lifestyle changes (e.g., low-sodium dietary and more physical exercise) needed to be made to help her control hypertension. Mary followed the medication recommendations, and she came back to the hospital after 2 weeks to have her blood pressure and glucose levels checked. During the visit, Mary told Tom that she had been taking her medication as ordered and had started a new exercise program in her daily life. Her friends asked her go out to eat some McDonald’s high-sodium food, but she refused and kept eating a low-sodium diet. Mary’s blood pressure was150/82 mmHg. and she had lost 1.12 kg over the past 2 weeks. After 1 month, Mary went to the hospital for another follow-up visit. She reported that she was still eating a low-sodium diet, taking the medication, and doing exercise. Her blood pressure was 124/73 mmHg, and she had lost 1.81 kg over the past month. Mary was encouraged and told the doctor that she was going to continue taking the medications and maintain a healthy lifestyle to control her blood pressure and glucose levels.

Bob was a 76-year-old man who was diagnosed with diabetes and hypertension about 6 years ago. When he went to hospital, his blood pressure was 181/97 mmHg. In the past, he had been prescribed blood pressure medication, but he failed to take the medication. Tom and Bob discussed the treatment options, and Bob seemed totally unconcerned with what the doctor said. Tom outlined the disadvantage of uncontrolled hypertension, and Bob showed his understanding and agreed to begin taking it. Tom told Bob that he needed to come to the hospital for a follow-up visit within the next week; however, Bob went to the hospital about 2 weeks later. During the visit, He told Tom that he had been administrating the medication as he had recommended. Tom checked his blood pressure, and it was 175/85mmHg. Tom increased the dosage of medication and told Bob to come back in 2 weeks. Bob did not come to the hospital until 2 months later. He was sent to the Emergency Department because of the respiratory infection and heart failure. His blood pressure was 181/89 mmHg, and he never took any medication to control his blood pressure. When Tom asked why he did not take the medication, he just told the doctor that he did not like how the medication made him feel.

The antecedents of adherence are the biomedical status of the individual, social support, self-efficacy, and education. Boyette et al.18 claimed that adherence for the elderly people in exercise was limited by biomedical status, socioeconomic status, education ,and past personal experience in exercise. In contrast, they noted that gender, age, and occupation did not impact adherence. Olowookere et al.19 noted that adherence was influenced by levels of education, physical environment, physician influence, and living status. This study found that poor adherence was especially high in newly diagnosed patients. When patients lack information on their illness, they feel more afraid of exercise engagement. Good education is associated with higher adherence, which can reduce the possibility of life-threatening complications (e.g., stroke and cardiac failure). Second, patients without family and social support had equally poor drug and exercise adherence, because caregivers and family members can help remind these patients to adhere to the medical recommendations. Fitzpatrick et al.4 identified self-motivation and physical self-efficacy as keys to adherence. They also thought that physical environment and physicianinfluence played an important role in adherence. Elderly people will follow an exercise program if they think that the exercise will improve their sleeping, strength, or overall health condition. On the other hand, negative outcome expectations, along with the fear of pain and safety risks, impacted adherence.

Good adherence to treatment recommendations enhances patient’s safety. It plays an essential role in the treatment of disease. Fitzpatrick et al. claimed that adherence promotes improved mental, physical, and social health and self-efficacy.4 Good adherence can promote healthy lifestyles such as not smoking, diet change, and increased physical activity. Furthermore, adherence influences disease treatment interventions and relapse prevention. Chawla et al.20 noted that improving adherence might be the lower cost and effective investment for reducing complications and disability, decreasing mortality and length of stay, and improving patients’ quality of life. The most important of all, its improved health outcomes can be a positive physical and social effect for the patients. This positive psychological effect is impacted by adherence. In contrast, poor adherence could lead to an increased risk of dependence, toxicity, rebound effect, and developing resistance to therapies; Roebuck et al.21 stated that almost half of all Americans live with at least one chronic disease. Continuing the use of prescribed medications and following the medical recommendations are a key component for chronic diseases. Patients who adhere to the medical recommendations and exercise treatments experience a higher quality of life and better outcomes. As a result of this, some urgent care and inpatient hospital services would be used less.

During the literature search, several measurement tools were used by nurse researchers in five studies of adherence from 2006 to 2016. Clark et al.22 found that self-report questionnaires and patient self-reporting were the most common measurement tools of adherence. It can provide an effective way of screening patients for nonad-herent behavior and is easy for health-care providers to use. Physiological parameters, illness perceptions, and treatment perceptions can also be used in the evaluation of treatment recommendations of adherence in the self-report questionnaires. Owing to the physiological factors (e.g., self-regulatory, biomedical, cognitive, behavioral, and communicative), underlying adherent behavior was complex; the study still had some low-risk participant bias in the measurement process. Furthermore, the reliable and valid instrument of monitoring adherence in the clinical settings is challenging. Electronic monitoring devices are also used to monitor medication adherence, and pill counts can be utilized. Medication event monitoring system can be used to access containers through a unique sensor on the lid of the containers and collect the data.23 Adherence may also be evaluated through the assessment of behaviors in the follow-up care.22 Milchak et al. explored JNC 7 adherence measurement tool of hypertension care;24 there are three treatment dimensions including laboratory, comorbidities, and follow-up intensity. Nevertheless, new tools should be developed, and the reliability of measurement tools must continually be evaluated.

The Theory of Planned Behavior is described as middle range theory. It can help people predict and explain an individual’s behavior. Attitudes, perceived behavioral control, subjective norms, and behavioral intension are four main constructs of the Planned Behavior Theory. Attitude refers to negative or positive evaluations of the behavior (e.g., treatment recommendations of adherence are good for the patient’s health condition); subjective norm refers to perceptions of pressure from others to perform the behavior (e.g., family members, partners, and friends would remind patient to perform treatment recommendations); and perceived behavioral control refers to judgment of whether it is easy or difficult to perform the behavior(e.g., it is easy for the patient to adhere to the treatment recommendations).

The Theory of Planned Behavior provides a framework to predict why patients change their behavior. The theory is also applied in predicting health behaviors and intentions including physical activity and dietary behaviors in patients with acute and chronic illnesses.25 Sabaté stated that adherence in chronic illness requires voluntary actions and engagement,6 because it is a long-term commitment of managing the disease by following the treatment recommendations by the health-care provider. For instance, exercise is easy to do and benefit health. People hold the attitude that “Adherence behavioral pattern is unnecessary for me.” or “I don’t need to do it.” Even though regular exercise is good for health condition, people are unlikely to stick to prescribed exercise unless they have a diagnosed disease (e.g., hypertension and diabetes). That being said, when an individual is diagnosed with a cardiac disease, nonadherence is more serious than simply not undertaking a healthy behavior. If the patient does not adhere to the treatment recommendations, their health condition might deteriorate rapidly.25 Behavior is determined by a person’s beliefs. Armitage and Conner noted that “the role of intention as a mediator of the effect of attitudes and subjective norms on behavior,26 and perceived behavioral control as a predictor of both intention and behavior.” Rich24 noted the effectiveness of the Planned Behavior Theory for predicting adherence to treatment recommendations in chronic illnesses across multiple studies. The study found that the Theory of Planned Behavior can explain the variance in intention and adherence behavior. Gipson and King showed that the Theory of Planned Behaviorhas been applied to predict the adherence of patients to change their health behavior successfully.27