Background
People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

Objectives
To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

Search methods
We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

Selection criteria
Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

Data collection and analysis
Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

Main results
For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 83 interventions reported in 70 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

Authors' conclusions
For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Interventions for enhancing medication adherence.

Conceptions of the body are central not only to substantive work in medical anthropology, but also to the philosophical underpinnings of the entire discipline of anthropology, where Western assumptions about the mind and body, the individual and society, affect both theoretical viewpoints and research paradigms. These same conceptions also influence ways in which health care is planned and delivered in Western societies. In this article we advocate the deconstruction of received concepts about the body and begin this process by examining three perspectives from which the body may be viewed: (1) as a phenomenally experienced individual body-self; (2) as a social body, a natural symbol for thinking about relationships among nature, society, and culture; and (3) as a body politic, an artifact of social and political control. After discussing ways in which anthropologists, other social scientists, and people from various cultures have conceptualized the body, we propose the study of emotions as an area of inquiry that holds promise for providing a new approach to the subject.

The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology

The effectiveness of efforts designed to address mental illness stigma will rest on our ability to understand stigma processes, the factors that produce and sustain such processes, and the mechanisms that lead from stigmatization to harmful consequences. Critical to such an understanding is our capacity to observe and measure the essential components of stigma processes. This article is designed to assist researchers in selecting or creating measures that can address critical research questions regarding stigma. Our conceptualization of stigma processes leads us to consider components of labeling, stereotyping, cognitive separating, emotional reactions, status loss, and discrimination. We review 123 empirical articles published between January 1995 and June 2003 that have sought to assess mental illness stigma and use these articles to provide a profile of current measurement in this area. From the articles we identify commonly used and promising measures and describe those measures in more detail so that readers can decide whether the described measures might be appropriate for their studies. We end by identifying gaps in stigma measurement in terms of concepts covered and populations assessed.

Measuring Mental Illness Stigma

ADHERENCE MAY BE DEFINED AS the extent to which a patient’s behavior (in terms of taking medication, following a diet, modifying habits, or attending clinics) coincides with medical or health advice. If a patient is prescribed an antibiotic for an infection to be taken as 1 tablet 4 times a day for a week but takes only 2 tablets a day for 5 days, the adherence would be 36% (10/28). The term adherence is intended to be nonjudgmental, a statement of fact rather than of blame of the prescriber, patient, or treatment. Compliance and concordance are synonyms for adherence. This simple definition of adherence belies the difficulties that many medical regimens present for patients. For example, the regimen described for type 2 diabetes mellitus in a previous article includes a special diet, increased exercise, smoking cessation, oral hypoglycemic drugs, and risk factor management, usually involving additional drugs. Such regimens fulfill theoretical, physiological, and empirical considerations about optimal care, while ignoring practical patient-centered concerns, such as the nature, nurture, culture, and stereotyping of the patient, and the inconvenience, cost, and adverse effects of the treatment. Indeed, low adherence with prescribed treatments is very common. Typical adherence rates for prescribed medications are about 50% with a range of 0% to more than 100%.

Interventions to Enhance Patient Adherence to Medication Prescriptions

ContextLow adherence with prescribed treatments is ubiquitous and undermines
treatment benefits.ObjectiveTo systematically review published randomized controlled trials (RCTs)
of interventions to assist patients' adherence to prescribed medications.Data SourcesA search of MEDLINE, CINAHL, PSYCHLIT, SOCIOFILE, IPA, EMBASE, The Cochrane
Library databases, and bibliographies was performed for records from 1967
through August 2001 to identify relevant articles of all RCTs of interventions
intended to improve adherence to self-administered medications.Study Selection and Data ExtractionStudies were included if they reported an unconfounded RCT of an intervention
to improve adherence with prescribed medications for a medical or psychiatric
disorder; both adherence and treatment outcome were measured; follow-up of
at least 80% of each study group was reported; and the duration of follow-up
for studies with positive initial findings was at least 6 months. Information
on study design features, interventions, controls, and findings (adherence
rates and patient outcomes) were extracted for each article.Data SynthesisStudies were too disparate to warrant meta-analysis. Forty-nine percent
of the interventions tested (19 of 39 in 33 studies) were associated with
statistically significant increases in medication adherence and only 17 reported
statistically significant improvements in treatment outcomes. Almost all the
interventions that were effective for long-term care were complex, including
combinations of more convenient care, information, counseling, reminders,
self-monitoring, reinforcement, family therapy, and other forms of additional
supervision or attention. Even the most effective interventions had modest
effects.ConclusionsCurrent methods of improving medication adherence for chronic health
problems are mostly complex, labor-intensive, and not predictably effective.
The full benefits of medications cannot be realized at currently achievable
levels of adherence; therefore, more studies of innovative approaches to assist
patients to follow prescriptions for medications are needed.

https://jamanetwork.com/journals/jama/articlepdf/195605/JSR20016.pdf

Interventions to enhance patient adherence to medication prescriptions: scientific review.

The authors define experience as an intersubjective medium of microcultural and infrapolitical processes in which something is at stake for participants in local worlds. Experience so defined mediates (and transforms) the relationship between context and person, meaning and psychobiology in health and illness and in healing. Building on this theoretical background, an approach to ethnography is illustrated through an analysis of suffering in Chinese society. The embodied memory of a survivor of serious trauma during the Cultural Revolution provides an example. From there, the authors go on to describe a framework of indigenous Chinese categories for the analysis of experience — mianzi (face), quanxi (connections), renqing (situated emotion), bao (reciprocity). The paper concludes with a discussion of the existential limits of this and other anthropological approaches to the study of experience as moral process.

Suffering and its professional transformation: toward an ethnography of interpersonal experience.

BACKGROUND We developed and evaluated a comprehensive, ongoing intervention for families of schizophrenic patients appropriate for China's complex family relationships and unique social environment.

METHOD Sixty-three DSM-III-R schizophrenic patients living with family members were enrolled when admitted to hospital and randomly assigned to receive standard care or a family-based intervention that included monthly 45-minute counselling sessions focused on the management of social and occupational problems, medication management, family education, family group meetings, and crisis intervention.

RESULTS At 6, 12, and 18-month follow-ups by blind evaluators, the proportion of subjects rehospitalised was lower, the duration of rehospitalisation was shorter, and the duration of employment was longer in the experimental group than in the control group; these differences were statistically significant at the 12 and 18-month follow-ups and were not explained by differences in drug compliance. Family intervention was associated with significantly lower levels of family burden.

CONCLUSIONS This intervention is less costly than standard treatment, is suitable for urban families of schizophrenic patients in China and feasible given the constraints of the Chinese mental health system.

Family-based intervention for schizophrenic patients in China. A randomised controlled trial.

The social course of epilepsy: chronic illness as social experience in interior China.

13. Somatization: The Interconnections in Chinese Society among Culture, Depressive Experiences, and the Meanings of Pain

AUL CONNERTON, writing in a widely cited essay that decisively summarizes the ideas of many social theorists, claims that collective and individual memory are so thoroughly interconnected, and that those interconnections are so central to how societies reproduce their social order across generations, that it is appropriate to analyze how societies remember.2 Basing his analysis on the integration of successive waves of interest in interpretive studies, Connerton professes that societies remember in three rather different ways: namely, through inscriptions onto cultural texts (myths, "great books," monuments); by way of commemorative rituals that engage people in participatory rationality and social action; and via incorporation of social memory into the human body.3 Connerton, drawing on the work of ethnographers and social historians, elaborates this evocative formula to illustrate what societies remember: namely, historical events, social

http://www.jstor.org/stable/pdfplus/469474.pdf

Joan Kleinman

Papers

Suffering and its professional transformation: toward an ethnography of interpersonal experience.

Family-based intervention for schizophrenic patients in China. A randomised controlled trial.

The social course of epilepsy: chronic illness as social experience in interior China.

13. Somatization: The Interconnections in Chinese Society among Culture, Depressive Experiences, and the Meanings of Pain

How Bodies Remember: Social Memory and Bodily Experience of Criticism, Resistance, and Delegitimation following China's Cultural Revolution