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5.2 Biomedical modelsTechnical adherence interventions imply a simplification of the regimen. There is robust evidencethat such simplifications regarding for example dosing and packaging improve patients

adherence. The underlying theoretical perspective of such interventions may be the bio-medical perspective, according to the theoretical analyses of Leventhal et al. [ !. "haracteristic of the bio-medical model are #technical solutions for patients adherence problems. $n this model, themedical experts seek solutions for patients problems. %atients need their expertise& they ask forhelp or advice.Let us consider the origins of this bio-medical perspective. $nitially, the biomedical model soughtthe reason for non-adherence in 'deviant( dispositional characteristics of the patient 'for example

personality characteristics, cognitive impairments, and so on(. These )ere sought in vain,ho)ever, because such factors )ere hardly found [ *!. The bio-medical studies found severalnon-dispositional factors in non-adherence, such as+ characteristics of the disease, severity ofsymptoms and features of treatment or side effects. These findings have motivated thedevelopment of technological #fixes to enhance compliance [ !.

The fact that simplification of regimen improves patients adherence is intuitively appealing. $tseems a practical and logical solution. Theoretically ho)ever, the operating mechanism in this bio-medical perspective is all but clear. hat exactly causes the patient to change his or her behavior $s taking one pill so much easier than taking t)o ccording to "laxton et al., thefindings reinforce the principle of simplicity [/0!. 1o)ever, no further theoretical explanations)ere given. %erhaps the lack of sound explaining mechanisms is one of the reasons )hy somerevie)ers sometimes categori2e technical adherence interventions under the behavioralapproaches [/*!.lthough the 3uest for technical solutions is as old as mankind itself, )e must confirm that as yetsound theoretical explanations for the effectiveness of simplification are lacking. The bio-medicalmodel does not provide us )ith causal explanations for patients behavior. This seems a firstchallenge for further theory development. %erhaps medical and social-psychology scientistsshould connect )ith scientists from other fields 'for example human engineering, ergonomics,technical sciences( to collaborate in the interests of further theory exploration.

5.3 Behavioral theoriesccording to our findings, interventions based on incentives and reminders can be successful inimproving patients adherence. They represent in fact the basic principles of behavior theory. Thistheory provides the follo)ing explanations for human behavior. 4ehavior depends on stimuli orcues that elicit certain responses, and on the re)ards that reinforce behavior. These are the mainand best kno)n original principles of behavior theory. The behavior may be learned by gradualshaping or patterning of the behavior. 5aintenance of the desired behavior may occur byautomation after sufficient repetition, and it may be helpful to avail of behavior se3uences, forexample a restructured environment to elicit responses and provide for re)ards [ !.6ver time, the behavioral approach has been )idened. 4andura incorporated principles fromsocial learning theories, for example modeling and vicarious learning 'learning by )atching,listening or reading(. 1e also added the concept of self-efficacy, the confidence in ones capacityto perform the desired behavior [*7!.6ur findings of relatively successful adherence interventions fit in the behavior perspective.4ehavioral adherence interventions focus directly on patients non-adherence behavior. Thereminders act as cues or stimuli that elicit certain responses and the incentives act as re)ards thatreinforce the desired behavior. $ncidentally, the term

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#re)ards should not be taken literally& re)ards may be all kinds of positive conse3uences of the behavior. 8eminders and incentives thus reflect the po)erful original principles of behaviortheory. 6ur findings sho) that reminders are successful in improving appointment keeping and assuch, sending reminders may considered to be one of the easiest adherence interventions. $tshould be noted ho)ever, that patients actual medication taking behavior seems less amenable toreminders. This remains a 3uestion for future research.

5.4 Educational perspectives%atient education appeared to be relatively successful in five revie)s. ccording to 4ro)n,#9ducational interventions are defined as any intervention given )ith the intent of improving the

persons ability to manage his:her disease, )hether it be in the cognitive, psychomotor or affectivedomains [; !. To make the meaning of !. Thus the concept of patient education is a complex one anddoes not solely refer to cognitive or didactic theoretical models.%atient education therefore may contain components of more than one theoretical mainstream.?nfortunately, )e do not kno) )hich components exactly contributed to the success of theeducational interventions because )e do not kno) )hich elements )ere present. The educationalrevie)s could not give an indication of the relative )eight of the various components, becauseoften details regarding the content of educational interventions )ere lacking or the descriptions)ere too broad to deduce the components 'for example the interventions made use of patientcounseling, self management programs, and so on(.s far as patient education focuses on transfer of information and kno)ledge about the diseaseand its treatment, the theoretical perspectives can be found in the communication models. Thesemodels emphasi2e conveying the message by trusted and affective messengers 'see belo)(. s far as educational interventions concentrate on changing patients ideas and 'mis(perceptions, thecognitive models may be the underlying theoretical perspective. The cognitive models emphasi2e

patients perceptions and beliefs as motivating factors for behavior. nd, as far as educationalinterventions are aimed at self-management, the underlying perspective may be the self-regulationmodels. These models emphasi2e the patients themselves as active problem solvers. e )ill givea short characteri2ation of each of these three theoretical mainstreams, )hich )ere originallydistinguished by Leventhal et al. in their theoretical analyses [ !.Communication perspectiveThe communication models focus on the message and the messenger. The patient should beinformed ade3uately. de3uate not only implies that patients understand and retain the message,additional conditions are re3uired for the communication to be effective in changing patientsattitude and motivation to adhere. %atients should believe in the message as )ell as in themessenger. They should accept the information on the treatment regimen and the benefits ofadherence behavior. The emphasis is on information about #)hy adherence is needed to influence

patients attitude and motivation. 6ther factors, external to the message itself, enhance acceptanceof the message. ffective components are re3uired, particularly a patients satisfaction )ith the

practitioner 'empathy,

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friendliness, interest, concern(. dditional information can facilitate behavior change, for exampleinformation about )ays incorporate the behavior into the patients daily routines.Cognitive perspectiveThe cognitive perspectives focus on cost:benefit analysis as a motivating factor to act '8ational

belief model, 1ealth 4elief model, Theory of 8easoned ction or %lanned 4ehavior(. Thesemodels assume that health related behavior is determined by perceived health threats and the benefits of health behavior. The )ell kno)n basic dimensions of the 1ealth 4elief 5odel are+ the perceived probability and severity of the threat on the one hand and the perceived benefits ofhealth behavior and the barriers to such behavior on the other hand. eighing the benefits and

barriers and the conse3uences of various behaviors provides the motivation for the actions to betaken. @uch )eighing is not based on obAective rational computations, but on the individuals o)nsubAective perceptions of the pros and cons. 5otivation is also determined by perceived social'group( norms and the perceived social conse3uences regarding the 'acceptability of( behavior.el! regulative modelsThese models emphasi2e the patients themselves as active problem solvers [*>,*/!. %atients try toclose the gap bet)een the current 'health( status and a goal. $n self-regulative models behavior is

considerably influenced by patients subAective experiences and emotions. 4ehavior depends on+B the patients perceptions of the current status and the goal&B the patients plans for changing the current status to reach the goal 'coping(&B the patients appraisal of the progress in reaching the goal.

$f goals are not reached, patients may change their perceptions 'the labeling of the status( and:ortheir )ay of coping. %atients )ays of coping depend on cognitive considerations, for example the

perceived identity of health threats and their labeling of the symptoms and potential causes.%arallel to these cognitive processes, emotional reactions may exist and interact. %atients )ill alsolabel 'the cause of( these emotions, and their coping aims to control or diminish 'stressful(emotions. 4oth cognitive and emotional )ays of coping may be triggered by internal stimuli 'forexample symptoms( or external stimuli 'for example media messages( [ !.e must conclude that as yet it is unkno)n )hether these three theoretical mainstreams aree3ually po)erful or po)erless in improving adherence. $t should be noted that each of thesetheories seems to be plausible for explaining adherence behavior& ho)ever, interventions derivedfrom these theories are not une3uivocally effective. e must conclude that there appears to be akno)ledge gap bet)een, on the one hand, explaining adherence behavior, and on the other hand,improving adherence behavior.6ur results so far indicate some obvious findings concerning the theoretical perspectivesunderlying adherence interventions+

B firstly, there are effective adherence interventions technical solutions - )ithout a cleartheoretical explanation of the operating mechanisms&

B secondly, there are effective adherence interventions incentives and reminders )hich

clearly stem from the behavior theory&B thirdly, there are many other theories )hich seem plausible for explaining non-adherence behavior, but these theories seem to be less po)erful in improving adherence behavior[*C!.

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6n the basis of this study )e formulated the follo)ing six propositions as tentative conclusions.These )ere presented for discussion to a selected forum of international adherence experts 'seennexes = and (. Their recommendations and final conclusions are reported in "hapter 0.

5.5 Six tentative propositions1. Current adherence theories are more successful in explaining than in improving

adherence: theor development should focus on improving adherence."urrent adherence theories seem ade3uate to explain and understand adherence behavior.

They seem to be less ade3uate for establishing effective adherence interventions. Dust as inmedical sciences, developments in diagnostics are superior to developments in therapy. shift in focus is needed in adherence theories.

2. !rogress in adherence theories might "e expected from con#oint efforts of medical$pharmaceutical$ social and technical scientists.

The importance of technical solutions in improving patient adherence points to ne) directionsin theory development. %rinciples of technical sciences, for example from humanengineering or ergonomics, could supplement the theories from medical and socialsciences.

3. %o improve adherence$ changing the situation seems more promising than changingthe patient.The results indicate that practical and technical solutions and environmental adaptations are

promising measures for improving adherence. dherence should be considered in relationto a patients environment. The starting point should be+ #)hat makes it easier for patientsto adhere

4. &dherence interventions should "e limited solel to non'adherent patients.$nterventions should be reserved for patients )ho need it. ?ntil no), most adherence

interventions have involved both adherent and non-adherent patients, leading to confusingand often contradictory findings. bout t)o thirds of patients are spontaneously adherent.To them interventions are a )aste of time and money and perhaps affect theirautonomy.$dentifying non-adherent patients is crucial. first indicator is failing clinical

progress. second indicator lies in doctor-patient communication. Eon-adherence should be discussed frankly and )ithout blame.

5. !atient groups should (help to) develop adherence interventions.5ost adherence interventions have been developed by health care providers. lthough

research has focused on patients reasons for non-adherence, patients have seldom beenasked )hat they need to facilitate adherence. The time has come to consult patient groupsabout their needs and their )ishes in relation to adherence.

*. %he main priorit : simple interventions +or,a"le in ("us ) clinical practice.dherence interventions are gro)ing increasingly complex. s a conse3uence they become

less )orkable in full-day 'busy( clinical practice. 5ost interventions re3uire extra staff,often enabled by research funding. 6ther solutions are needed in clinical practice.

3* Patient adherence to medical treatment: a meta review, NIVEL 2006