In July and August 2015, I completed a medical volunteer trip in Lima with the organization International Volunteer HQ. I wanted to experience a different health care system and practice my skills as a nursing student. In Peru, poverty creates a large barrier from accessing healthcare for a significant portion of the population. To increase access to care, the government of the Callao region has installed a “clinibus” program which I was involved in. It consists of a bus that travels to different areas providing specialist care. The government covers the cost of visits and most medications; however many clients do not follow the prescribed treatment. During my time in Peru, I observed a lack of information on how to administer treatments, limited understanding of the importance of routine treatment, and distrust of health care professionals.
Clients are described as non-adherent when they seem to agree with the recommendations of their health care professionals, however later do not follow through, whether voluntarily or involuntarily. For example, clients may not follow dietary restrictions, recommendations for weight loss, or for smoking cessation. Non-adherence can also relate to medications, such as not filling prescriptions, skipping doses, missing refills or discontinuing medications altogether. Missing appointments and not following up on referrals are forms of non-adherence as well.
In Callao, a client had difficulty reading her handwritten prescription. She was prescribed salbutamol, a bronchodilator used in asthma treatment, and could not distinguish how often it was prescribed. I noticed that there were no instructions on the box. Upon speaking with her further, her questions revealed that she did not understand why and how to administer the medication. I was shocked when she asked me if she was supposed to take the inhaler by nose or by mouth! Since very few clients ask questions during their consultation, and limited instructions are given or available, I realized that non-adherence may be common in the clinibus program.
Non-adherence is not exclusive to Peru; it has been referred to as “Canada’s other drug problem.” The World Health Organization (2003) estimates that in developed countries such as Canada, adherence to long-term therapies for chronic illnesses averages just 50%. Taking medications improperly can be dangerous for the client as negative outcomes can include unnecessarily increasing the severity symptoms or progression of the condition, increasing need for more medications, causing hospitalization, and even death (World Health Organization, 2003). In addition, non-adherence has a significant economic burden due to increased complications and health care visits (World Health Organization, 2003). Several factors can cause clients not to follow their physician’s guidance, such as lack of understanding, interest, or commitment. About 1 in 10 Canadians who receive a prescription report the cost of the medication as a reason for non-adherence (Law, Cheng, Heard & Morgan, 2012).
Hypertension Canada recommends a multidisciplinary approach involving a simplified treatment plan, client education, and increased client responsibility to assist patients in adhering to treatment. Client responsibility can be increased with collaboration, negotiation, and sometimes compromise between health care professionals and clients (Martin, Williams, Haskard & DiMatteo, 2005). Also, interventions that are tailored to clients, disease conditions, and treatment regimens are more likely to be successful (McDonald, Garg & Haynes, 2002). Finally, by engaging clients, family members, health care professionals, and policy makers in the ongoing discussion surrounding non-adherence, unique solutions to this challenge are bound to be discovered.
Hypertension Canada (n.d.). Adherence strategies for patients. Retrieved from https://www.hypertension.ca/en/professional/chep/therapy/adherence-strategies-for-patients
Law, M. R., Cheng, L., Dhallan, I. A., Heard, D., & Morgan, S. G. (2012). The effect of cost on adherence to prescription medications in Canada. Canadian Medical Association Journal, 184(3). doi:10.1503/cmaj.111270
Martin, L. R., Williams, S. L., Haskard, K. B., & DiMatteo, M. R. (2005). The challenge of patient adherence. Therapeutics and Clinical Risk Management, 1(3), 189-199.
McDonald, H. P., Garg, A. X., Haynes, R. B. (2002). Interventions to enhance patient adherence to medication prescriptions: Scientific review. JAMA, 288(22), 2868-79.
World Health Organization. (2003). Adherence to long-term therapies: Evidence for action. Switzerland: WHO Library Cataloguing-in-Publication Data. Retrieved from: http://www.who.int/chp/knowledge/publications/adherence_full_report.pdf