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.

The fear appeal literature is examined in a comprehensive synthesis using meta-analytical techniques. The meta-analysis suggests that strong fear appeals produce high levels of perceived severity and susceptibility, and are more persuasive than low or weak fear appeals. The results also indicate that fear appeals motivate adaptive danger control actions such as message acceptance and maladaptive fear control actions such as defensive avoidance or reactance. It appears that strong fear appeals and high-efficacy messages produce the greatest behavior change, whereas strong fear appeals with low-efficacy messages produce the greatest levels of defensive responses. Future directions and practical implications are provided.

A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns

https://in.bgu.ac.il/en/fohs/communityhealth/Family/Documents/DOCTOR-PATIENT%20COMMUNICATION%20A%20REVIEW%20OF.pdf

Doctor-patient communication: a review of the literature.

OBJECTIVE: To review the relationship between literacy and health outcomes DATA SOURCES: We searched MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resources Information Center (ERIC), Public Affairs Information Service (PAIS), Industrial and Labor Relations Review (ILLR), PsychInfo, and Ageline from 1980 to 2003 STUDY SELECTION: We included observational studies that reported original data, measured literacy with any valid instrument, and measured one or more health outcomes Two abstractors reviewed each study for inclusion and resolved disagreements by discussion DATA EXTRACTION: One reviewer abstracted data from each article into an evidence table; the second reviewer checked each entry The whole study team reconciled disagreements about information in evidence tables Both data extractors independently completed an 11-item quality scale for each article; scores were averaged to give a final measure of article quality DATA SYNTHESIS: We reviewed 3,015 titles and abstracts and pulled 684 articles for full review; 73 articles met inclusion criteria and, of those, 44 addressed the questions of this report Patients with low literacy had poorer health outcomes, including knowledge, intermediate disease markers, measures of morbidity, general health status, and use of health resources Patients with low literacy were generally 15 to 3 times more likely to experience a given poor outcome The average quality of the articles was fair to good Most studies were cross-sectional in design; many failed to address adequately confounding and the use of multiple comparisons CONCLUSIONS: Low literacy is associated with several adverse health outcomes Future research, using more rigorous methods, will better define these relationships and guide developers of new interventions

/pdf/literacy-and-health-outcomes-4pmopsjgz6.pdf

Literacy and health outcomes

Role theory Concerns One of the most important features of social life, characteristic behavior patterns or roles. It explains roles by presuming that persons are members of social positions and hold expectations for their own behaviors and those of other persons. Its vocabulary and concerns are popular among social scientists and practitioners, and role concepts have generated a lot of research. At least five perspectives may be discriminated in recent work within the field: functional, symbolic interactionist, structural, organizational, and cognitive role theory. Much of role research reflects practical concerns and derived concepts, and research on four such concepts is reviewed: consensus, conformity, role conflict, and role taking. Recent developments suggest both centrifugal and integrative forces within the role field. The former reflect differing perspectival commitments of scholars, confusions and disagreements over use of role concepts, and the fact that role theory is used to analyze various forms of social system. The latter reflect the shared, basic concerns of the field and efforts by role theorists to seek a broad version of the field that will accommodate a wide range of interests.

/pdf/recent-developments-in-role-theory-2hca5dk92y.pdf

Recent developments in role theory

Patients' satisfaction patients' understanding of what they are told memory for medical information the problem of patients' non-compliance relationships between understanding, memory, satisfaction and compliance techniques for increasing patients' recall and understanding another problem - non-compliance by health care professionals the use of written information selecting the content of communications the benifits of improved communication.

Communicating with Patients: Improving Communication, Satisfaction and Compliance

The literature on communication, compliance, and patient satisfaction is selectively reviewed. As in earlier reviews, it is concluded that dissatisfaction with communication remains widespread, as does lack of compliance with medical advice. Related factors include poor transmission of information from patient to doctor, low understandability of communications addressed to the patient, and low levels of recall of information by patients. There does not appear to be any evidence that provision of additional information leads to adverse reactions by patients. Theoretical approaches to communication and compliance are described, and it is concluded that these should be used to direct future research.

Satisfaction, compliance and communication

The frequency with which patients fail to recall advice presented by their doctors is discribed. The amount forgotten is shown to be a linear function of the amount presented, to be correlated with the patient's medical knowledge, anxiety level and possibly age, but not with intelligence. It is probable that instructions and advice are more often forgotten than other information, and that this is the result of their low perceived importance, and their being presented late in the series of statements presented-there being (a) a primacy effect in recall of medical information, and (b) a tendency for statements perceived as more important to be better recalled. Experiments to control the content and amount of forgetting are described. Control of content can be obtained by use of the primacy and importance effects, while control of amount forgotten can be achieved by use of (a) simpler language, (b) explicit categorization, (c) repetition, and (d) concrete-specific rather than general-abstract advice statements.

Memory for medical information

Readability formulas are being increasingly used to measure the understandability of written information in clinical and health settings. This paper examines the most commonly used formulas (Dale-Chall Formula, Flesch Reading Ease, Flesch-Kincaid Formula, Fog Index, Fry Readability Graph, and SMOG Grading). Their reliability and validity when used in health-related areas are discussed, and findings resulting from their use are described. These findings show that much of the material written for patients and clients, in the areas of informed consent, illnesses and their investigation and treatment, and lifestyle advice, is too difficult for many of them to understand. It is also concluded that increasing readability usually leads to improvement in understanding and occasionally in co-operation with treatment. Finally, methods for supplementing the information gained from readability formulas are described.

The use of readability formulas in health care

Patients' views were sought by questionnaires and home visits on how satisfied they were with the care they received from their general practitioners and how much of the advice received they were prepared to accept. The results showed a high degree of satisfaction and a higher level than has been found in hospital. Studies like this may identify difficulties which some patients may have and help doctors to make difficult advice easier to follow.

P. Ley

Papers

Communicating with Patients: Improving Communication, Satisfaction and Compliance

Satisfaction, compliance and communication

Memory for medical information

The use of readability formulas in health care

Patients' satisfaction and reported acceptance of advice in general practice.