Chest ACCP Member Benefits
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Guest Access | Sign In via User Name/Password
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via ISI Web of Science (15)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by George, J.
Right arrow Articles by Stewart, K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by George, J.
Right arrow Articles by Stewart, K.
(Chest. 2005;128:3198-3204.)
© 2005 American College of Chest Physicians

Factors Associated With Medication Nonadherence in Patients With COPD*

Johnson George, MPharm, PhD; David C. M. Kong, BPharm, MPharm, PhD; Rambha Thoman, Dip Physio and Kay Stewart, BPharm (Hons), PhD

* From the Department of Pharmacy Practice (Drs. George, Kong, and Stewart), Victorian College of Pharmacy, Monash University; and Acute Physiotherapy (Ms. Thoman), Frankston Hospital, Victoria, Australia.

Correspondence to: Kay Stewart, BPharm (Hons), Senior Lecturer, Department of Pharmacy Practice, Victorian College of Pharmacy, Monash University, 381 Royal Parade, Parkville, VIC 3052, Australia; e-mail: Kay.Stewart{at}vcp.monash.edu.au


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: To identify the predictors of medication adherence in patients with COPD and contrast the health beliefs, experiences, and behaviors of COPD patients self-reporting good adherence with those of patients reporting suboptimal adherence to their medications.

Design: Cross-sectional self-administered questionnaire.

Setting: Ambulatory care.

Participants: Patients with chronic respiratory ailments identified through respiratory support groups and from a pulmonary rehabilitation database.

Measurements and results: A 30-item questionnaire comprising items pertaining to health beliefs, experiences, and behaviors along with a valid self-reported measure of adherence—the medication adherence report scale (MARS)—was administered to 525 ambulatory patients with chronic lung conditions. A total of 276 usable responses were received (52.6%). The mean age of the respondents was 71 years, and there were slightly more male patients (54.4%). COPD was the underlying disease condition in 90.6% of the respondents; two thirds of the respondents had comorbid conditions. The respiratory condition was managed by both general practitioners and respiratory specialists in 61.2% of cases. One third of the respondents self-reported complementary and alternative medicine use. The mean score (± SD) on the MARS among the respondents was 23.37 ± 2.09. One hundred two patients self-reported perfect adherence on the MARS. Differences in knowledge about the illness and treatment, faith in and satisfaction with the treatment and doctors, concerns about the treatment, and intentional and unintentional deviations from the recommended treatment were detected between the adherent and less adherent groups. In multivariate analysis, "I vary my recommended management based on how I am feeling" and "I get confused about my medications" were found to be significant independent predictors of nonadherence.

Conclusions: Patients’ acceptance of the disease process and recommended treatment, knowledge about and faith in the treatment, effective patient-clinician interaction, and routinization of drug therapy are critical for optimal medication adherence in patients with COPD.

Key Words: adherence behavior • beliefs • COPD • experiences • medication • predictors


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
COPD is currently the fifth-leading cause of global mortality and a major public health problem in both developed and developing countries.1 By the year 2020, COPD is expected to become the third-most-common cause of death in the world and the fifth-leading cause of disease burden.2 Progressive introduction of pharmacologic, nonpharmacologic, and surgical treatments are often necessary to cope with the deteriorating respiratory function in COPD patients.3 Acute exacerbations are the most frequent cause of hospital admissions and death among COPD patients.4 Frequent exacerbations also reduce the quality of life in patients with COPD.5

Adherence is defined as "the extent to which a person’s behavior (in terms of taking medications, following diets, or executing lifestyle changes) coincides with medical or health advice."6 Patient nonadherence is one of the best documented but least understood health-related behaviors. Factors pertaining to disease, treatment, patient, clinician, and the practice setting have been identified as the determinants or risk factors for nonadherence.78910 Sociologic, psychological, physician-based systems and models have been used for investigating adherence in different studies.1112131415

COPD patients have been found to be nonadherent with their treatment recommendations both intentionally and unintentionally.161718192021 Poor adherence to drug therapy and disease management programs has been identified as the major factor resulting in emergency hospitalization among COPD patients.222324 However, better medication adherence was associated with both decrease in the number of hospitalizations and length of hospital stay among patients with chronic respiratory ailments.25 Several factors predispose COPD patients to nonadherence. Management of COPD is complex, with patients needing to make behavioral and lifestyle changes such as smoking cessation and adherence to exercise therapy along with optimal medication adherence.3 Multiple comorbidities are common among patients with COPD, and they are often prescribed complex medication regimens comprising time contingent and as-needed medications to be administered by multiple routes for both respiratory and nonrespiratory conditions.1726 Depression, a common comorbidity in patients with COPD,2728 is a known risk factor for nonadherence.2930 In one study,31 a verbal memory pattern conforming to that of same-age normal subjects was seen in only a fifth of COPD patients.

It is known that patients are more likely to adhere to treatments when they perceive the recommended treatment makes "common sense" in the light of their personal beliefs about the illness and their experiences with past illness and/or current symptoms.32 Patient decisions to follow the recommended treatment are likely to be influenced by their beliefs about medicines as well as their beliefs about the illness that the medication is intended to treat or prevent.33 The role of health beliefs in treatment adherence has been recognized as a priority for adherence research.3435

Adherence research in COPD has mainly focused on quantification of the problem, except for a few studies172136 that have attempted to identify the factors influencing nonadherence. Very little attention has been paid to the patients’ perspectives of adherence. The aims of this study were to contrast the health beliefs, experiences, and behaviors of COPD patients self-reporting good adherence and suboptimal adherence to their medications and to identify the predictors of medication adherence.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Health beliefs, experiences, and behaviors (practices) pertaining to adherence and nonadherence were identified through content and thematic analysis of in-depth interviews with a purposive sample of COPD patients chosen from patients participating in a community-based randomized trial. The identified themes were developed into a questionnaire with statements grouped under three sections: beliefs, experiences, and behaviors (practices). Two pharmacists with experience in respiratory medicine and two pharmacy practice researchers were asked to evaluate the relevance, clarity, and conciseness of the items included in the questionnaire. The medication adherence report scale (MARS)3738 was added to the questionnaire as a patient self-reported measure of adherence. Higher scores on the MARS suggest better adherence (a score of 25 indicates perfect adherence). The questionnaire was pilot tested on three patients with chronic respiratory ailments.

Patients with chronic lung conditions attending 12 respiratory support groups and one pulmonary rehabilitation center (Peninsula Health) in Victoria, Australia were targeted for the study. Questionnaires were forwarded to the group leaders/coordinators, who were requested to distribute the questionnaires during their regular group meetings or send them to the group members by mail. A nutrition guide for patients with COPD was included as an ethically acceptable incentive to encourage patient response. The study received approval from the Monash University Scientific Committee on Ethics in Research involving Humans and the Peninsula Health Research & Ethics Committee.

A total of 277 questionnaires were forwarded to the group leaders/coordinators of the various respiratory support groups. Questionnaires were sent to all 297 patients in the pulmonary rehabilitation database by the coordinator of the program (R.T.). Forty-nine questionnaires were returned to the sender either due to change of address or deceased addressee. Reminder letters were sent to all patients in the pulmonary rehabilitation database, irrespective of their response, 4 weeks after the initial mailing. All patients received reminders, as the investigators had no access to the mailing list. Group leaders of respiratory support groups were requested to remind their group members about the questionnaire 4 weeks after the date of distribution of the questionnaire.

Data Analysis
Continuous demographic and clinical variables were compared using Student t test. Beliefs, experiences, and behaviors of the adherent group were compared with the less adherent group using the Mann-Whitney U statistic. A logistic regression analysis was then performed on those items with significant differences between the adherent and nonadherent groups, using total scores on the MARS as the dichotomous outcome variable (score of 25 = high adherence; < 25 = suboptimal adherence) to identify the independent predictors of nonadherence.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Thirty items were generated to reflect the major themes pertaining to beliefs, experiences, and adherence behaviors identified through content and thematic analysis of the in-depth interviews. A total of 280 responses were received (53.3% response rate); of these, 276 responses were usable (52.6%) [4 responses had to be excluded due to more than five items left unanswered].

There were more male (54.4%) than female patients among the respondents. The respiratory condition was managed by both GPs and respiratory specialists in 61.2% of cases, GPs alone in 19.8% of cases, and respiratory specialists alone in 8.7% of cases. GPs along with respiratory specialists and cardiologists were in charge of the management in 8.0% of patients. COPD was the underlying disease condition in 90.6% of the respondents, while asthma (5.4%), bronchiectasis (2.2%), and others (eg, lung carcinoma, lungectomy) [1.8%] were the other respiratory conditions reported by the respondents. The majority of respondents (85%) had a history of smoking; only 10 patients (3.7%) reported continuing to smoke at the time of the study. Complementary and alternative medicine (CAM) use was self-reported by one third of the participants. Two thirds of the respondents had comorbid conditions. At least one course of pulmonary rehabilitation had been completed by 80% of the study subjects.

The mean score on the MARS in the study population was 23.37 ± 2.09. A total of 102 patients (51 men and 51 women) self-reported high adherence on the MARS (score = 25), while 164 patients reported suboptimal adherence. Among the 182 nonusers of CAM, high adherence was self-reported by 79 patients (43%), while only 21 of the 89 CAM users (24%) had a perfect score on the MARS. High adherence was observed in only 57 of the 172 patients with comorbidities (33%), while 45 of the 93 patients who did not have any comorbidities (48%) self-reported perfect adherence. Among patients who completed pulmonary rehabilitation, 81 patients (38%) reported good adherence; 18 of the 41 patients who did not undergo pulmonary rehabilitation (44%) self-reported high adherence. No significant differences were observed between patients who self-reported perfect adherence and those who reported suboptimal adherence in their demographic and clinical features (Table 1 ). Health beliefs, experiences, and behaviors of the high adherent group are compared with their counterparts in Tables 234, respectively.


View this table:
[in this window]
[in a new window]

  		Table 1. Characteristics of the Respondents*

 

View this table:
[in this window]
[in a new window]

  		Table 2. Health Beliefs of the Respondents*

 

View this table:
[in this window]
[in a new window]

  		Table 3. Health Experiences of the Respondents*

 

View this table:
[in this window]
[in a new window]

  		Table 4. Health Behaviors of the Respondents*

 
When logistic regression was performed on total MARS scores, a model comprising all the significant variables from the univariate analysis explained 26% variance in nonadherence. "I vary my recommended management based on how I am feeling" and "I get confused about my medications" were found to be significant independent predictors of nonadherence, while "My doctors spend adequate time with me" was just short of reaching statistical significance (p = 0.07). These three variables together explained 19.5% variance in nonadherence in the study population.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Patient beliefs, experiences, and behaviors with regards to both disease and treatment were found to be more powerful predictors of medication adherence than sociodemographic and clinical factors in patients with COPD. The variance in adherence explained by these factors was on par with or greater than those reported by other models of adherence.39404142434445 Significant differences in health beliefs, experiences, and behaviors were observed between COPD patients with high medication adherence and suboptimal adherence. The understanding of these factors could assist in enhancing health outcomes in patients with COPD.

The extent of suboptimal adherence identified in the present study (63%) is greater than the suspected medication nonadherence in the long term for different disease conditions (50%).6 This is a concern considering the extent of educational interventions to which the study population is likely to have been subjected. COPD being a symptomatic disease, patients are likely to alter the recommended management based on how they feel. Patient education focusing on the pathology of the disease and the need for long-term treatment might help in improving patient adherence. The prevalence of confusion about medications in the nonadherent group suggests the need for additional education and the use of adherence aids such as medication lists and dosette boxes, especially in the elderly and those with a complex medication regimen. Our findings suggest that this need exists even for patients who have undergone pulmonary rehabilitation and those who participate in respiratory support groups. This study highlights the need for doctors to spend more time with their patients, especially those whose nonadherence is of concern.

Adherent patients had greater understanding about their illness and the options for managing the illness. They also had greater confidence that current management would keep their illness under control. However, management of illness was a mystery for patients with suboptimal adherence, and they had greater faith in the safety of natural remedies. Dowell and Hudson46 concluded that accepting the recommended treatment, especially long-term treatment perceived as powerful, requires an acceptance of the illness. Other studies474849 have shown that confidence in drug therapy could be low among COPD patients. The health belief model5051 suggests that a patient’s perception of the effectiveness of a recommended behavior (action) predicts the likelihood of taking that behavior. Studies of various patient groups have shown patients’ perceived benefits from the treatment to be associated with medication use.2152535455

Satisfaction with and faith in the treating physician were found to be low among the less adherent group compared to the highly adherent group. These factors are known from other studies to be critical for optimal adherence in both COPD and other patient populations.365657 The importance of effective patient-clinician interaction for optimal adherence to therapeutic regimens is well recognized.575859 Empathic understanding is considered to be one of the most important practitioner relationship skills leading ultimately to patient health benefit.59 Patient satisfaction was the only factor that had significant correlation with different measures of medication adherence in a study45 on patients with chronic diseases including pulmonary disease.

Patients who reported suboptimal adherence found their medications to be more physically challenging and unpleasant compared to their counterparts. Complexity of medication regimens and the number of regular medications in the regimen were not significant predictors of nonadherence in the present study. Unlike reported in previous studies6061 of chronic respiratory patients, there were no differences between the adherent and less adherent groups in their concerns about side effects from the medications. Although cost of treatment is generally regarded as a barrier to adherence,7 the differences between the two groups for the item on financial restrictions was not significant, and the responses of both the groups were negative. In Australia, prescription medications are subsidized by the government through the Pharmaceutical Benefits Scheme. This, along with special privileges for pensioners, might have made health care affordable for most study participants.

There were no significant differences between the adherent and less adherent groups in their perception of control over illness management. However, less adherent patients believed that their doctors had limited management options to offer them. According to Dowell and Hudson,46 patients who accept their medication regimen fully as prescribed by their doctors are likely to assume a passive role in managing their illness and relinquish control to their doctor. In a study21 of patients receiving supplemental oxygen therapy, patients had the perception that adhering to a doctor’s prescription generally promoted their health; however, for proper management of their disease, many believed that they had to remain vigilant themselves and retain independence in their decisions. Nevertheless, the failure of the locus of control theory in explaining any significant proportion of variance in adherence in previous studies1845 confirms that control over management is not a significant independent predictor of treatment nonadherence in patients with chronic respiratory ailments.

Differences in both intentional and unintentional health behaviors were observed between the two groups. Adherent patients were less likely to be confused about their medications, which might have been the result of their greater medication knowledge. Less adherent patients were more likely to vary their recommended management to suit their lifestyle or based on how they felt. The difference between the two groups for the item on routines almost reached statistical significance. "Routinization," ie, the ability to fit a medication regimen to one’s daily routine, has been recognized as a major determinant of improved adherence.62 It is not surprising in a disease condition like COPD, in which people are encouraged to increase their doses when feeling unwell, that they may decrease the doses when they feel well.63 Patients with suboptimal adherence were also likely to put up with their medical problems before taking any action. Many patients participating in a primary care study were found to fight the disease and tended to use the least amount of the medication when possible.46 Changes in adherence patterns with disease severity, symptoms, and therapeutic response have been reported among COPD patients.202126365564

Two thirds of the study subjects had comorbidities, suggesting the possible relevance of these findings in patients with other chronic ailments. Depression is known to be a risk factor for nonadherence,2930 but we avoided any specific questions about depression in the questionnaire due to the sensitivity of the topic and concerns about patient nonresponse. The mean age of the current study population was > 70 years. The relatively greater adherence observed among the participants might have been the result of more organized behavior in old age. It is possible that the results are biased given the response rate of only 52.6%. However, it is likely that those who responded to the questionnaire had greater adherence than the nonrespondents. Extrapolation of the findings of this study to other COPD patients, especially younger ones, should be done with caution. The cross-sectional design of the study does not allow the drawing of any conclusions on the cause-effect relationship between nonadherence and health beliefs and experiences. Adherence was assessed by self-report and the validity of self-reports has been criticized.65666768 Being an anonymous questionnaire, it is unlikely that any of the patients gave incorrect responses in an attempt to please the researchers. Items such as race, languages spoken, education, financial status, and social support were not included in the questionnaire because the associations between adherence and these factors have been found to be inconsistent across studies.

Predictors of adherent behavior and differences in health beliefs, experiences, and behaviors of adherent and less adherent patients with COPD were identified. Patients’ acceptance of the disease process and recommended treatment, knowledge about and faith in the treatment, effective patient-clinician interaction, and routinization of drug therapy are critical for optimal medication adherence in COPD patients.


   Footnotes
 
Abbreviations: CAM = complementary and alternative medicine; GP = general practitioner; MARS = medication adherence report scale

Received for publication March 19, 2005. Accepted for publication May 19, 2005.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. World health report 2004 World Health Organization. Geneva, Switzerland:
  2. Murray, CJ, Lopez, AD Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. Lancet 1997;349,1498-1504[CrossRef][ISI][Medline]
  3. Pauwels, RA, Buist, AS, Calverley, PM, et al Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med 2001;163,1256-1276[Free Full Text]
  4. Regueiro, CR, Hamel, MB, Davis, RB, et al A comparison of generalist and pulmonologist care for patients hospitalized with severe chronic obstructive pulmonary disease: resource intensity, hospital costs, and survival: Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Am J Med 1998;105,366-372[CrossRef][ISI][Medline]
  5. Seemungal, TA, Donaldson, GC, Paul, EA, et al Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998;157,1418-1422[ISI][Medline]
  6. Haynes, RB, Taylor, DW, Sackett, DL Compliance in healthcare. 1979,1-7 Johns Hopkins University Press. Baltimore, MD:
  7. Haynes, RB Determinants of compliance: the disease and the mechanics of treatment. Haynes, RB Taylor, DW Sackett, DL eds. Compliance in healthcare 1979,49-62 Johns Hopkins University Press. Baltimore, MD:
  8. Tabor, PA, Lopez, DA Comply with us: improving medication adherence. J Pharm Pract 2004;17,167-181[CrossRef]
  9. Vik, SA, Maxwell, CJ, Hogan, DB Measurement, correlates, and health outcomes of medication adherence among seniors. Ann Pharmacother 2004;38,303-312[Abstract/Free Full Text]
  10. Meichenbaum, D, Turk, DC Facilitating treatment adherence: a practitioner’s guidebook. 1987 Plenum. New York, NY:
  11. Ogden, J Health psychology. 2000 Open University Press. Buckingham, UK:
  12. Bandura, A. Self-efficacy: the exercise of control 2003 W. H. Freeman and Company. New York, NY:
  13. Marlatt, GA, Gordon, JR Relapse prevention: maintenance strategies in the treatment of addictive behaviors. 1985,351-416 Guilford Press. New York, NY:
  14. Prochaska, JO, DiClemente, CC, Norcross, JC In search of how people change: applications to addictive behaviors. Am Psychol 1992;47,1102-1114[CrossRef][Medline]
  15. Zimmerman, GL, Olsen, CG, Bosworth, MF A "stages of change" approach to helping patients change behavior. Am Fam Physician 2000;61,1409-1416[ISI][Medline]
  16. Rand, CS, Nides, M, Cowles, MK, et al Long-term metered-dose inhaler adherence in a clinical trial: The Lung Health Study Research Group. Am J Respir Crit Care Med 1995;152,580-588[Abstract]
  17. Dolce, JJ, Crisp, C, Manzella, B, et al Medication adherence patterns in chronic obstructive pulmonary disease. Chest 1991;99,837-841[Abstract/Free Full Text]
  18. Apter, AJ, Reisine, ST, Affleck, G, et al Adherence with twice-daily dosing of inhaled steroids: socioeconomic and health-belief differences. Am J Respir Crit Care Med 1998;157,1810-1817
  19. van Grunsven, PM, van Schayck, CP, van Deuveren, M, et al Compliance during long-term treatment with fluticasone propionate in subjects with early signs of asthma or chronic obstructive pulmonary disease (COPD): results of the Detection, Intervention, and Monitoring Program of COPD and Asthma (DIMCA) Study. J Asthma 2000;37,225-234[ISI][Medline]
  20. Pepin, JL, Barjhoux, CE, Deschaux, C, et al Long-term oxygen therapy at home: compliance with medical prescription and effective use of therapy. ANTADIR Working Group on Oxygen Therapy Association Nationale de Traitement a Domicile des Insuffisants Respiratories. Chest 1996;109,1144-1150[Abstract/Free Full Text]
  21. Earnest, MA Explaining adherence to supplemental oxygen therapy: the patient’s perspective. J Gen Intern Med 2002;17,749-755[CrossRef][ISI][Medline]
  22. Col, N, Fanale, JE, Kronholm, P The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med 1990;150,841-845[Abstract]
  23. Fuso, L, Incalzi, RA, Pistelli, R, et al Predicting mortality of patients hospitalized for acutely exacerbated chronic obstructive pulmonary disease. Am J Med 1995;98,272-277[CrossRef][ISI][Medline]
  24. Garcia-Aymerich, J, Barreiro, E, Farrero, E, et al Patients hospitalized for COPD have a high prevalence of modifiable risk factors for exacerbation (EFRAM study). Eur Respir J 2000;16,1037-1042[Abstract]
  25. Balakrishnan, R, Christensen, DB Inhaled corticosteroid use and associated outcomes in elderly patients with moderate to severe chronic pulmonary disease. Clin Ther 2000;22,452-469[CrossRef][ISI][Medline]
  26. Chryssidis, E, Frewin, DB, Frith, PA, et al Compliance with aerosol therapy in chronic obstructive lung disease. N Z Med J 1981;94,375-377[ISI][Medline]
  27. Mapel, DW, Picchi, MA, Hurley, JS, et al Utilization in COPD: patient characteristics and diagnostic evaluation. Chest 2000;117,346S-353S[Abstract/Free Full Text]
  28. van Manen, JG, Bindels, PJ, Dekker, FW, et al Risk of depression in patients with chronic obstructive pulmonary disease and its determinants. Thorax 2002;57,412-416[Abstract/Free Full Text]
  29. DiMatteo, MR, Lepper, HS, Croghan, TW Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000;160,2101-2107[Abstract/Free Full Text]
  30. Bosley, CM, Corden, ZM, Rees, PJ, et al Psychological factors associated with use of home nebulized therapy for COPD. Eur Respir J 1996;9,2346-2350[Abstract]
  31. Incalzi, RA, Gemma, A, Marra, C, et al Verbal memory impairment in COPD: its mechanisms and clinical relevance. Chest 1997;112,1506-1513[Abstract/Free Full Text]
  32. Leventhal, H, Diefenbach, M, Leventhal, EA Illness cognition: using common sense to understand treatment adherence and affect cognition interactions. Cognitive Ther Res 1992;16,143-163
  33. Horne, R Representations of medications and treatment: advances in theory and measurement. Petrie, KJ Weinman, JA eds. Perceptions of health and illness 1997,155-188 Harwood Academic. London, UK:
  34. Marinker, M Personal paper: writing prescriptions is easy. BMJ 1997;314,747-748[Free Full Text]
  35. Marinker, M, Blenkinsopp, A, Bond, C, et al From compliance to concordance: achieving shared goals in medicine taking. 1997 Royal Pharmaceutical Society of Great Britain. London, UK:
  36. Turner, J, Wright, E, Mendella, L, et al Predictors of patient adherence to long-term home nebulizer therapy for COPD: the IPPB Study Group; intermittent positive pressure breathing. Chest 1995;108,394-400[Abstract/Free Full Text]
  37. Horne, R The medication adherence report scale. 2004 University of Brighton. Brighton, UK:
  38. Medicines partnership: from compliance to concordance. Medicines Partnership Task Force, 2002; Available at: medicines-partnership.org/about.us/history--context. Accessed August 29, 2005
  39. Horne, R, Weinman, J Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. J Psychosom Res 1999;47,555-567[CrossRef][ISI][Medline]
  40. Venturini, F, Nichol, MB, Sung, JC, et al Compliance with sulfonylureas in a health maintenance organization: a pharmacy record-based study. Ann Pharmacother 1999;33,281-288[Abstract]
  41. Christensen, AJ, Moran, PJ, Wiebe, JS Assessment of irrational health beliefs: relation to health practices and medical regimen adherence. Health Psychol 1999;18,169-176[CrossRef][ISI][Medline]
  42. Becker, MH, Maiman, LA, Kirscht, JP, et al Patient perceptions and compliance: recent studies of the health belief model. Haynes, RB Taylor, DW Sackett, DL eds. Compliance in healthcare 1979,78-109 The Johns Hopkins University Press. Baltimore, MD:
  43. Tillotson, LM, Smith, MS Locus of control, social support, and adherence to the diabetes regimen. Diabetes Educ 1996;22,133-139
  44. Dishman, RK, Ickes, W, Morgan, WP Self-motivation and adherence to habitual physical activity. J Appl Soc Psychol 1980;10,115-132
  45. Nagy, VT, Wolfe, GR Cognitive predictors of compliance in chronic disease patients. Med Care 1984;22,912-921[CrossRef][ISI][Medline]
  46. Dowell, J, Hudson, H A qualitative study of medication-taking behaviour in primary care. Fam Pract 1997;14,369-375[Abstract/Free Full Text]
  47. Incalzi, RA, Pedone, C, Onder, G, et al Predicting length of stay of older patients with exacerbated chronic obstructive pulmonary disease. Aging (Milano) 2001;13,49-57[Medline]
  48. Taylor, DR, Kinney, CD, McDevitt, DG Patient compliance with oral theophylline therapy. Br J Clin Pharmacol 1984;17,15-20[ISI][Medline]
  49. Borak, J, Sliwinski, P, Piasecki, Z, et al Psychological status of COPD patients on long term oxygen therapy. Eur Respir J 1991;4,59-62[Abstract]
  50. Rosenstock, I The health belief model and preventative health behaviour. Health Educ Monogr 1974;1974,354-386
  51. Becker, MH, Haefner, DP, Kasl, SV, et al Selected psychosocial models and correlates of individual health-related behaviors. Med Care 1977;15,27-46[Medline]
  52. Benson, J, Britten, N Patients’ decisions about whether or not to take antihypertensive drugs: qualitative study. BMJ 2002;325,873[Abstract/Free Full Text]
  53. Buston, KM, Wood, SF Non-compliance amongst adolescents with asthma: listening to what they tell us about self-management. Fam Pract 2000;17,134-138[Abstract/Free Full Text]
  54. Remien, RH, Hirky, AE, Johnson, MO, et al Adherence to medication treatment: a qualitative study of facilitators and barriers among a diverse sample of HIV+ men and women in four US cities. AIDS Behav 2003;7,61-72[CrossRef][ISI][Medline]
  55. Dompeling, E, Van Grunsven, PM, Van Schayck, CP, et al Treatment with inhaled steroids in asthma and chronic bronchitis: long-term compliance and inhaler technique. Fam Pract 1992;9,161-166[Abstract/Free Full Text]
  56. Dietrich, UC Factors influencing the attitudes held by women with type II diabetes: a qualitative study. Patient Educ Couns 1996;29,13-23[CrossRef][ISI][Medline]
  57. Ciechanowski, PS, Katon, WJ, Russo, JE, et al The patient-provider relationship: attachment theory and adherence to treatment in diabetes. Am J Psychiatry 2001;158,29-35[Abstract/Free Full Text]
  58. Hulka, BS Patient-clinician interactions and compliance. Haynes, RB Taylor, DW Sacket, DL eds. Compliance in health care 1979,63-77 The Johns Hopkins University Press. Baltimore, MD:
  59. Squier, RW A model of empathic understanding and adherence to treatment regimens in practitioner-patient relationships. Soc Sci Med 1990;30,325-339[CrossRef][ISI][Medline]
  60. Dowson, CA, Town, GI, Frampton, C, et al Psychopathology and illness beliefs influence COPD self-management. J Psychosom Res 2004;56,333-340[CrossRef][ISI][Medline]
  61. Boulet, LP Perception of the role and potential side effects of inhaled corticosteroids among asthmatic patients. Chest 1998;113,587-592[Abstract/Free Full Text]
  62. Ryan, GW, Wagner, GJ Pill taking "routinization": a critical factor to understanding episodic medication adherence. AIDS Care 2003;15,795-806[CrossRef][ISI][Medline]
  63. James, PN, Anderson, JB, Prior, JG, et al Patterns of drug taking in patients with chronic airflow obstruction. Postgrad Med J 1985;61,7-10[Abstract]
  64. De Blaquiere, P, Christensen, DB, Carter, WB, et al Use and misuse of metered-dose inhalers by patients with chronic lung disease: a controlled, randomized trial of two instruction methods. Am Rev Respir Dis 1989;140,910-916[ISI][Medline]
  65. Spector, SL, Kinsman, R, Mawhinney, H, et al Compliance of patients with asthma with an experimental aerosolized medication: implications for controlled clinical trials. J Allergy Clin Immunol 1986;77,65-70[CrossRef][ISI][Medline]
  66. Nides, MA, Tashkin, DP, Simmons, MS, et al Improving inhaler adherence in a clinical trial through the use of the nebulizer chronolog. Chest 1993;104,501-507[Abstract/Free Full Text]
  67. Garber, MC, Nau, DP, Erickson, SR, et al The concordance of self-report with other measures of medication adherence: a summary of the literature. Med Care 2004;42,649-652[CrossRef][ISI][Medline]
  68. Liu, H, Golin, CE, Miller, LG, et al A comparison study of multiple measures of adherence to HIV protease inhibitors. Ann Intern Med 2001;134,968-977[Abstract/Free Full Text]




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via ISI Web of Science (15)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by George, J.
Right arrow Articles by Stewart, K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by George, J.
Right arrow Articles by Stewart, K.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS