Adherence to medication and treatment guidelines: most important, but often overlooked (2023)

short communicationResumePDF DOI:

Abdul Kader Mohiuddin*

Alumni, Faculty of Pharmacy, University of Dhaka, Bangladesh

*Corresponding author:Abdul Kader Mohiuddin, Alumni, Faculty of Pharmacy, University of Dhaka, Bangladesh, Tel: +01935183385, ORCID: 0000-0003-1596-9757, Web of Science Researcher ID: T-5428-2019; The e-mail:[email protected]

Reception date:December 1, 2022

Publication date:December 21, 2022

Quote:Mohiuddin AK. (2022). Adherence to Medication and Treatment Guidelines: Most Important, But Mostly Overlooked. Mathews J Pharma Sci. 6(1):12.

Copyright:Mohiuddin AK. ©(2022).


(Video) Medication Adherence: Landscape, Strategies, and Evaluation Methods

To cure any disease, it is necessary to use the medicine properly or to take the medicine in the correct order. Even patients in developed countries struggle to maintain medication adherence. There is a strange parallel between the emerging underdeveloped nations and the so-called developed world in the West when it comes to drug abuse. Understanding and perception of the disease is the most important factor influencing patients to adhere to their treatment plan.

Keywords: Medication non-compliance, patient non-compliance, avoidable medical costs.


Adverse Drug Reactions (ADRs)

Blood pressure (BP)

Non-steroidal anti-inflammatory drugs (NSAIDs)

The Centers for Disease Control and Prevention (CDC)

World Health Organization (WHO)


To cure any disease, it is necessary to use the medicine properly or to take the medicine in the correct order. According to the WHO, non-adherence to therapeutic schemes generates great problems for patients, especially those with chronic diseases. The "correct administration" depends on at least 5 correct factors: correct patient, correct drug, correct time, correct dose and correct route [1]. "Medications just won't work if you don't take them correctly": Most people around the world don't understand this simple fact, and as a result, more than half of chronic disease patients in the developed world don't take their medicines . correctly, according to the WHO [2]. Patients with chronic illnesses may find it difficult to adhere because their medications must be taken over a long period of time, sometimes for the rest of their lives. Patients can have difficulty adhering to treatment regimens for a variety of reasons, and the CDC estimates that medication non-adherence accounts for 30-50% of chronic disease treatment failures. Poor adherence can lead to treatment failure, worsening of symptoms, and deterioration of health [3].

(Video) Overcoming Barriers to Medication Adherence for Chronic Diseases

Figure 1.Non-adherence to medication and possible results.

Non-adherence in so-called developed countries

In the UK, up to 50% of medications are not taken as prescribed and 60% of NHS patients do not receive adequate treatment within 18 weeks [4-6]. In patients with chronic diseases, nonadherence to medications leads to worse health outcomes, higher healthcare costs, more hospitalizations, and even higher mortality rates [7]. Medication nonadherence alone accounts for at least 10% of hospitalizations in the US, 250,000 hospitalizations in Australia, and 1.1 million hospital days in France (Figure 1) [8-10 ]; causes $300 billion in annual medical costs in the United States and $125 billion in the European Union; and causes more than 1,25,000 premature deaths in the United States and 2,00,000 deaths in the European Union [8,11,12]. Furthermore, two thirds of drug-related hospitalizations in Australia are potentially preventable [9]. According to a recent Canadian study, 30% of patients stop taking their medication earlier than recommended and 25% do not comply with the prescription or take less than prescribed [13]. Nonadherence to medication attributed to $679-$898 more avoidable expenses among patients who had at least one avoidable encounter [14]. However, pharmaceutical companies around the world lost $637 billion in potential sales due to non-adherence, with $250 billion lost in the US alone last year (Figure 1) [15].

Misuse of antibiotics

More than half of all antibiotics sold worldwide are sold without a prescription, and the CDC reports that 30-50% of antibiotics prescribed in hospitals are inappropriate or unnecessary [16,17]. According to a recent Lancet study funded by the Bill and Melinda Gates Foundation and the Wellcome Trust, nearly 5 million deaths worldwide in 2019 were caused by bacterial resistance, which is expected to double by 2050 [18]. In South Asia, nearly 70% of hospitalized patients received one or more antibiotics, while 100% of ICU patients received antibiotics [19,20]. However, between 70% and 80% of patients with COVID-19 have received multiple antibiotics for the treatment of COVID-19 [21-23]. The most frequently prescribed antibiotics were azithromycin, ceftriaxone, amoxicillin, metronidazole, and amoxicillin-clavulanic acid [24]. Furthermore, it has been reported that around 90% of patients with COVID-19 are being treated unnecessarily with antibiotics and almost 100% of these prescriptions were empiric [25].

NSAID abuse in patients with COVID-19, Dengue and Chikungunya

NSAIDs are responsible for at least 650,000 hospitalizations, 165,000 deaths, and 30% of ADR-related hospital admissions worldwide each year [26,27]. Excessive use of this class of drugs can lead to kidney damage, and its side effects can be three to four times more severe in patients with kidney disease [28]. Many studies have found that these drugs are widely used in patients with dengue, chikungunya, and Covid-19. It is even more important to keep the body hydrated than to lower the fever with painkillers, especially in patients with Dengue or Covid-19. Excessive use of paracetamol syrup or suppositories in children can cause gastric irritation, which can lead to vomiting and hospitalization. With a few exceptions, most hospitalizations or ICU admissions among these patients could be avoided simply by stopping dehydration at home with saline and fruit juice or by simply drinking more water [29].

A new era of rampant prescription and recreational drug use

Sleep disturbances are reported by approximately 40% of Covid-19 patients. Benzodiazepines increase the risk of delirium in patients with Covid-19, depress the system in patients with compromised respiratory functions, and are contraindicated with some antiviral drugs [30,31]. Surprisingly, the distribution of benzodiazepines increased dramatically in Canada between 2020 and 2021, while the abuse of similar drugs more than doubled in Italy [32]. According to the American Journal of Public Health [33], approximately 300 metric tons of morphine-type pain relievers are used worldwide each year, with less than 1% distributed to low- and middle-income countries. As a result, the developed world retains its misuse and associated side effects. Leading up to the US mid-term elections, an announcement by authorities about the “simple possession of marijuana” for thousands of convicted citizens ignited recreational drug abuse in the US and the EU [34,35].

Negative attitude towards the Covid-19 vaccine

A cross-sectional study of 259 school leaders in Hong Kong conducted during the COVID-19 pandemic between April 2021 and February 2022 shows that more than 50% of the participants had limited health literacy, which was strongly associated with a negative attitude towards vaccination, confusion about information related to COVID-19, and secondary symptoms [36]. Previously, a 2020 US study found that two-thirds of Americans will not receive the COVID-19 vaccine when it first becomes available, while 25% report they have no intention of getting vaccinated anytime soon. term [37]. In India, vaccine reluctance was high in Tamil Nadu, over 40%, and willingness to accept the vaccine was close to 90% in Kerala [38,39]. Another survey of vaccine hesitancy from University College London, UK, found mistrust among 16% of respondents and 23% were confused [40].

(Video) Medication-Assisted Treatment for Opioid Use Disorder: Improving Adherence and Outcomes

Medical cost and low health literacy: the two main barriers to adherence in patients with diabetes

A strange similarity can be found in underdeveloped and developing countries and the so-called developed world in the West or the Middle East when it comes to not taking medicines correctly. According to a WHO report, only half of patients in developed countries adhere to treatment guidelines for chronic diseases, which is much lower in developing countries [41]. Several studies among diabetic patients in South Asian countries have shown that almost half of patients do not adhere to prescribed medication and are at risk of acute and long-term complications, resulting in increased rates of hospitalization and medical costs [42, 43]. “Medical costs are barriers to compliance with appropriate clinical guidelines for chronic diseases in poor countries”, although they are discussed in many forums, but forgetfulness, confusion about the required duration of drug use and mistrust about the effectiveness General medication are some of the reasons. for non-compliance with diabetes control protocols in Middle Eastern countries [44]. Health literacy and medication adherence are strongly associated (Table 1). Poor glycemic control due to low health literacy among patients with diabetes reported in Southeast Asian and Middle Eastern countries [45-51].

Humanitarian crisis: Poor blood pressure control among heart patients

A recent study by the American Heart Association revealed that patients with high blood pressure do not follow treatment guidelines due to: (a) suboptimal doses or incorrect prescription of medications (b) lack of insurance or lack of access to medical care, and (c) patient non-compliance with prescribed medication or other lifestyle guidelines [52]. Among hypertensives, less than 50% have persistent BP control, although more patients received treatment over time. In addition, inadequate BP control has been reported among those with elevated total cholesterol, LDL, and uric acid levels in high-, low-, and middle-income countries [53]. The humanitarian crisis is associated with increased short- and long-term cardiac morbidity and mortality and increased BP [54]. For example, hypertensive patients with diabetes mellitus were twice as likely to have poor blood pressure control as in war-torn Palestine [55]. Additionally, a US survey of resettled Rohingya refugees from Myanmar shows a higher trend of chronic diseases such as diabetes, hypertension, and obesity [56].

Superstitions: an elephant in the room

Epilepsy and schizophrenia are still seen in most countries of the world as an evil spirit; although two-thirds of patients can be seizure-free with appropriate treatment, failure to adhere to appropriate regimens is a major problem for effective recovery [57, 58] . In a study conducted in India, 60% of patients believed in luck and superstition in relation to disease [59]. Superstitions have also been reported in about 40% of men and 70% of women in northern Germany [60]. In Africa, 70% of people resort to indigenous treatments such as spells and witchcraft to treat their illnesses [61]. Shockingly, more than 40% of Americans believe in spiritual treatment, and researchers have found that 73% of addiction treatment programs in the US include a spirituality-based element [62, 63]. The phobia was the cause of insulin rejection among 60% of diabetic patients despite medical recommendations, as found in a study conducted in southern Iran [64].

Pediatric and geriatric complications of non-adherence

Due to multiple physical complications and additional medication burden, three quarters of geriatric people worldwide are unable to adhere to appropriate long-term treatment regimens (Figure 1) [65]. Patients over the age of 65 who are taking at least five medications are at increased risk of mild cognitive impairment, memory loss, falls, frailty, impairment, and death, while ADRs are estimated to account for 5-28% of cases severe geriatric disease. admissions [66, 67]. For children, common non-adherences are related to family routines, parenting problems, and social problems such as poverty. Long-term conditions such as asthma, cystic fibrosis, HIV, diabetes, inflammatory bowel disease, and juvenile arthritis are attributable to approximately 60% of nonadherence among children [68-70].

Tabla 1.Several reasons identified for non-adherence to treatment guidelines for chronic diseases [7,71-73].





Socioeconomic status of the patient

Low health literacy, lack of a family or social support network, unstable life or homelessness, financial insecurity


treatment related

Complexity and duration of treatment procedures, frequent changes in medication regimen, lack of immediate results, real or perceived unpleasant side effects, lifestyle interference


Related to the health system

High treatment costs, limited health care system for patient education and follow-up, doctor-patient relationship, patient dependency on health care, long wait times, lack of patient information materials


patient related

Visual-auditory and cognitive impairment, mobility and dexterity, psychological and behavioral factors, perception of risk of susceptibility to diseases, superstitions and stigmatization of the disease, etc.

Tools to improve adherence to medication and treatment guidelines

There is evidence that the number of chronic diseases and medications increases non-adherence. The management of chronic diseases requires continuous psychological adaptation through behavioral, educational, integrated care, self-care, and risk communication interventions, which can result in significant changes in therapeutic indications. In addition, several newer technologies have been incorporated that may improve adherence to treatment and medication regimens.

(Video) Treatment Adherence in Diabetes Management: The Single Most Important Attribute to Optimum Outcomes

Mesa 2.Interventions to improve adherence to treatment guidelines.



Psychological Adaptation Training - ABC Taxonomy

The first scenario,initiation, is measured as a time-to-event variable and refers to the interval between the prescription and the patient taking the first dose of a prescribed drug. The second phase,Implementation, is a continuous measure of the difference between the amount of medication prescribed and actually consumed. Covers the time from the first dose to the last dose. The third stage, known asdiscontinuation, denotes the end of therapy, when the next dose is missed and no further doses are administered thereafter. The term "persistence”, which is often used, refers to a time-to-event variable that measures how long a patient spends in the implementation phase [74].

behavioral interventions

There are four steps involved in the formation of behavior: attention, retention, reproduction, and motivation. Telephone follow-up and home visits, particularly in association with educational components, appear to have a positive impact, providing planning and support before and after discharge and integrated interventions [75].

patient education

Health promoters often have credibility to carry out patient education programs due to their specialized knowledge and adequate training. However, knowledge alone does not guarantee success as a health educator. The following three guidelines should be followed in patient education programs: To change patients' health-related behaviors, it is important to address the following factors: (a) establishing a relationship between patients and health professionals; (b) deliver and evaluate the objectives of the patient education program; and (c) paying attention to patients with low self-esteem and non-verbal [76].

Integrated care interventions

An interdisciplinary approach relies on healthcare professionals from different disciplines, together with the patient, working collaboratively as a team. The doctor, pharmacist, or nurse invites the patient to participate in the program, but in practice, the doctor is often the best person to invite the patient to participate in the program because of the professional-patient relationship that is established [77].

self-care interventions

The medication self-management intervention consists of two weekly phone calls and three face-to-face education sessions spread over six weeks. To identify the factors that affect adherence, as well as how and why these factors contribute to poor adherence, a comprehensive assessment of adherence problems will first be performed. Depending on each patient's condition and potential adherence issues, medication-related knowledge and skills will be offered. For a better understanding of the cognitive factors of patients that influence adherence behaviour, motivational interviewing techniques will be used [78].

Risk communication interventions

Patients and health professionals exchange risk information in both directions. The key to reducing the risk of drug-related traffic accidents is the verbal communication of information and the use of simple documents. Providing patients with accurate information can improve their sense of self-efficacy and satisfaction, which can lead to behavior changes and risk reduction. [79, 80].


Finally, it can be stated that the patient's knowledge and interpretation of the disease are the main factors influencing adherence to the therapeutic scheme. Health professionals should explore more effective health education methods to identify patients' attitudes toward illness, trust in medicine, psychological stressors, and increase medication adherence.


I am grateful to Daniel B. Mark, MD, Duke Clinical Research Institute, Duke University Medical Center, North Carolina, USA, for his valuable time reviewing my article and for his thoughtful suggestions. . I am also grateful to Dhaka University College of Pharmacy Seminary Library and Bangladesh BANSDOC Library for providing me with books, magazines and newsletters.




The author declares that he has no conflicting interests.



(Video) Medication Adherence


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What is the most common reason a patient is non compliant with medication adherence? ›

A major barrier to adherence is often the cost of the medicine prescribed to the patient. The high cost may lead to patients not filling their medications in the first place. They may even ration what they do fill in order to extend their supply.

What is the most effective strategy for improving patient adherence to the care regimen? ›

Nine Tips for Improving Medication Adherence
  1. Educate patients about what to expect. ...
  2. Nurture relationships with patients. ...
  3. Team up with prescribers. ...
  4. Engage the staff. ...
  5. Learn about and use available technologies. ...
  6. Help patients customize their support tools. ...
  7. Schedule appointments. ...
  8. Synchronize medications.
Dec 6, 2016

What is the importance of medication adherence? ›

Taking your medicine as prescribed or medication adherence is important for controlling chronic conditions, treating temporary conditions, and overall long-term health and well-being. A personal connection with your health-care provider or pharmacist is an important part of medication adherence.

What are the challenges of patient adherence? ›

Knowing the patient as a person allows the health professional to understand elements that are crucial to the patient's adherence: beliefs, attitudes, subjective norms, cultural context, social supports, and emotional health challenges, particularly depression.

What are the common barriers to adherence? ›

Barriers to good medication adherence according to the general practitioners (GPs)
  • Poor knowledge of the illness and medication.
  • Administering and dosage of the medication.
  • Independent pausing, stopping or controlling of the medication.
  • Lack of competence in self-management.

What factors are known to negatively influence adherence? ›

Previous research has indicated that adherence is influenced by a number of issues, including side effects, cost of the medication, dosing frequency, and routes of administration.

What are three strategies you can use to improve patient adherence? ›

Successful strategies to improve medication adherence include 1) ensuring access to providers across the continuum of care and implementing team-based care; 2) educating and empowering patients to understand the treatment regimen and its benefits; 3) reducing barriers to obtaining medication, including cost reduction ...

What is the most accurate method of measuring adherence? ›

Electronic medication monitoring

Electronic adherence measurement devices have been even regarded as the “gold standard” of adherence measurement.

What kind of interventions would you build to help improve medication adherence? ›

10 Strategies to Improve Patient Compliance with Medication
  • Understand each patient's medication-taking behaviors. ...
  • Talk about side effects. ...
  • Write it down. ...
  • Collaborate with patients. ...
  • Consider the financial burden to the patient. ...
  • Assess health literacy. ...
  • Reduce complexity. ...
  • Follow up with patients.
Jan 22, 2020

What is poor treatment adherence? ›

A third type of non adherence is known as non conforming, this type includes a variety of ways in which medication are not taken as prescribed, this behavior can range from skipping doses, to taking medications at incorrect times or at incorrect doses, to even taking more than prescribed.

What are systemic barriers to medication adherence? ›

Some potential barriers (ie, factors associated with nonadherence) were identified from the studies, including patient-related factors such as disease-related knowledge, health literacy, and cognitive function; drug-related factors such as adverse effects and polypharmacy; and other factors including the patient- ...

What are the four key elements of adherence therapy? ›

There are six elements that form the core of the therapy: assessment; medication problem-solving; a medication timeline; exploring ambivalence; discussing beliefs and concerns about medication; and using medication in the future.

What are the five factors that contribute to adherence? ›

Adherence is a multifactorial problem that can be influenced by various factors. The factors can be roughly divided in the following five dimensions: Social and economic, health care system, health condition, therapy and patient [3].

What is the importance of adherence to work methods and procedures? ›

They ensure compliance with laws and regulations, give guidance for decision-making, and streamline internal processes. However, policies and procedures won't do your organization any good if your employees don't follow them. Employees don't always like the idea of having to follow the rules.

Why is improving patient adherence to treatment important? ›

Medication non-adherence results in billions of avoidable costs for healthcare systems around the world, due to repeated hospital admissions and increased physician visits. “Medications are prescribed in a particular way to optimize health outcomes,” said Dr.

What are the 5 main barriers? ›

Definition of Barriers

There are five key barriers that can occur within a company: language, cultural diversity, gender differences, status differences and physical separation. These barriers to communication are specific items that can distort or prevent communication within an organization.

What are the 7 barriers to effective? ›

The Seven Barriers to Communication
  • Physical Barriers. ...
  • Perceptual Barriers. ...
  • Emotional Barriers. ...
  • Cultural Barriers. ...
  • Language Barriers. ...
  • Gender Barriers. ...
  • Interpersonal Barriers. ...
  • Break Through The Barriers.

What are the six common barriers? ›

Below are six common barriers to effective organizational change, along with strategies and suggestions on how to manage them.
  • 1) Individual Change Resistance. ...
  • 2) Lack of Communication. ...
  • 3) Lack of Strategic Direction. ...
  • 4) Lack of Consistency. ...
  • 5) Cultural Barriers. ...
  • 6) Lack of (Perceived) Leadership Buy-In.
Aug 28, 2018

What is the most important factor in patient compliance? ›

The most important factors related to the medications affecting patient compliance are efficacy, dosage schedule, and the delivery mechanism. Patients are more likely to avoid taking drugs they believe to be non-effective, as well as those with complex dosage requirements and delivery mechanisms.

What is the main reason for noncompliance with medication administration? ›

One of the major reasons that patients become non adherent is because they forget to take their medications. Results of a study conducted showed that 49.6% of patients mentioned forgetfulness as one of the major non-intentional reasons for non adherence.

What causes patient non compliance? ›

Patient's lack of understanding.

Noncompliance often occurs when patients don't understand why they're taking a certain medication. Help them understand the purpose of the medication and why and how it will benefit them. Also, describe potential side effects.

Why would a patients be non compliant? ›

These are a few of the common reasons for non-compliance and non-adherence: Cost and affordability. Lack of understanding/comprehension of advice, whether due to language barriers, cognitive abilities, being afraid to ask for clarification or other reasons. Mistrust or a lack of strong patient-provider relationship.

What are the possible causes for noncompliance? ›

Common Causes of Noncompliant Behavior
  • Failure of Communication and Lack of Comprehension. ...
  • Cultural Issues. ...
  • “Psychological” Issues. ...
  • Secondary Gain. ...
  • Psychosocial Stress. ...
  • Drug and Alcohol Dependence.

What are three concerns related to non-compliance? ›

Risks of noncompliance
  • 1) Hefty fines and penalties. Businesses that are out of compliance face fines and penalties from a number of regulations. ...
  • 2) Reputation damage. Fines and penalties aren't the only damage you might incur from noncompliance — your business reputation is on the hook as well. ...
  • 3) Legal action.
May 8, 2020

What is the most common implication of noncompliance? ›

The most well-known consequence of non-compliance is the financial loss from government action, which can take the form of: Fines. Limitations on your business activities. Legal fees associated with a legal investigation.

How do you address medication noncompliance? ›

The following are ten strategies that providers can use to boost medication compliance.
  1. Understand each patient's medication-taking behaviors. ...
  2. Talk about side effects. ...
  3. Write it down. ...
  4. Collaborate with patients. ...
  5. Consider the financial burden to the patient. ...
  6. Assess health literacy. ...
  7. Reduce complexity. ...
  8. Follow up with patients.
Jan 22, 2020

How do you get patients to comply with treatment? ›

Strategies for improving compliance include giving clear, concise, and logical instructions in familiar language, adapting drug regimens to daily routines, eliciting patient participation through self-monitoring, and providing educational materials that promote overall good health in connection with medical treatment.

What are two consequences of non compliance? ›

Consequences of non-compliance with legislation
  • Fines. We can't throw an entire company in jail, so the most common consequence for corporations who breach legislation is a fine. ...
  • Removal from ASX. ...
  • Insurance. ...
  • Unenforceable Contracts. ...
  • Criminal Consequences. ...
  • Tax Liability.

What does poor patient compliance mean? ›

Compliance is defined as “the extent to which the patient's behavior matches the prescriber's recommendations.”5 Its use implies the “lack of patient involvement” and is associated with negative characteristics such as yielding and submission.

What are the examples of patient noncompliance? ›

Common manifestations of patient noncompliance include:
  • Failure to keep follow-up appointments.
  • Failure to complete recommended diagnostic testing or laboratory studies.
  • Failure to comply with consultation recommendations.
  • Failure to follow medication instructions and monitoring regimens.

Why patients don t follow medical advice? ›

Patients may not heed the guidance provided by their physicians for many reasons. Changes may be difficult for the patient, either because of other obligations, lack of commitment, interest, or understanding. Socio-economic conditions may mean treatments are unaffordable or living conditions are difficult.

What is the biggest challenge facing healthcare today? ›

1. The High Cost of Health Care. The problem: Perhaps the most pressing issue in health care currently is the high cost of care. More than 45% of American adults say it's difficult to afford health care, according to a survey by the Kaiser Family Foundation, and more than 40% have medical debt.

What is the term for a patient who fails to follow the doctor's advice? ›

Health care. _____________ is when a patient does not follow a doctor's advice. Noncompliance.


1. Medication Adherence in Children by Dr. Celeste Ewig (in English)
(ChildSim HK - 抄先貼堂)
2. Rachel Fournier: Targeting medication non adherence behavior in immunology A systematic approach to
(Stanford Medicine X)
3. Strategies for Ensuring Adherence to LTBI Treatment
(Global Tuberculosis Institute)
4. From Compliance To Alliance When Talking About Medication
(International Bipolar Foundation)
5. Adherence to Medical Treatment (Christina Duncan, PhD)
(MAHSA University)


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