When patients seek medical advice, providers give it in good faith. Maybe they write a prescription, suggest an exercise plan, or refer the patient to a specialist. Ultimately, the provider expects the patient to follow their expert recommendation. So why do around 44% fail to do so? And why does it matter?
Adherence—another word for patient follow-through or healthcare compliance—affects all of us whether or not we’re the patient. Poor adherence prevents people from enjoying a higher quality of life, wastes money and resources, and can lead to health complications, incorrect diagnoses, and the spread of disease.
Adherence is often associated with taking medication, but it spans a much broader spectrum of treatments and behaviors, including attending appointments, getting vaccinated, eating healthier foods, practicing safe sex, brushing and flossing teeth, doing therapeutic exercises, and avoiding tobacco, drugs, and alcohol. The scope is huge and the stakes are high.
So, what can we do about it? Let’s take a look at what researchers have discovered about the root causes of nonadherence, recommended practices for patients, providers, and other stakeholders, and some examples of how people are leveraging human-centered design for improved healthcare compliance.
According to the World Health Organization (WHO), characteristics like age, sex, race, religion, marital status, education level, occupation, and personality don’t usually play a significant role in adherence. Follow-through also doesn’t seem to hinge on whether someone has an acute versus chronic illness or a physical versus behavioral concern.
Instead, studies suggest adherence is largely determined by our emotions, perceptions, social supports, and health literacy. And there’s no single issue that blocks patient follow-through—it’s a complex, multifaceted issue that requires multiple solutions.
Some common themes crop up over and over again in adherence research, including
Let’s look at each of these in more detail.
In one U.S. study, 35% of English-speaking participants and 62% of Spanish-speaking participants were found to have poor health literacy, meaning they were unable to read, understand, and follow written medical instructions. This affected their ability to correctly take medication on an empty stomach and to understand the scheduling of their next appointment, resulting in poor adherence.
In the WHO’s analysis of adherence across nine chronic illnesses, issues like “inadequate understanding of the disease,” “lack of information about the prescribed daily dosage,” “poor health education of the patient,” “misunderstanding instructions about how to take the drugs,” and “lack of clear instructions from health professionals” were often cited as having a negative effect on adherence. In contrast, understanding the disease and receiving clear instructions had a positive effect on adherence.
Forgetfulness can happen to anyone, not just folks diagnosed with memory problems. In some cases, patients understand verbal instructions during their appointment but forget the details shortly after. According to a landmark 1965 study, this occurs 56% of the time.
Even when people don’t forget the instructions, they may forget to complete the task when the time comes—whether it’s to take medicine, perform a therapeutic exercise, or go to another appointment.
When patients trust their health care providers, they’re 2.6 times more likely to adhere to their treatments. But why?
According to Przemyslaw Kardas, the founder and director of the Medication Adherence Research Center, emotions and perceptions drive the decision-making process. When someone trusts their provider and has a positive perception of the treatment plan, they’re more likely to follow it.
Other studies support the idea that adherence and information recall improve when patients feel more comfortable with their providers. Empathetic, active listening, a warm demeanor, and continuity of care have been identified as important factors in building a positive patient-provider relationship.
Patients who aren’t fully on-board with their treatment plans are unlikely to follow through with them. They may believe the treatment is unnecessary or unsafe; they may feel anxious about side effects, pain, or potential drug dependence; or they may not accept their diagnosis. Negative stigmas can also prevent people from attending therapy, using assistive devices, or taking medication.
Patient buy-in is closely linked with health literacy and the provider relationship. According to the WHO, “patients who view themselves as partners in the treatment process [...] have better adherence behavior and health outcomes.” Likewise, Laranjeira et al. say shared decision making between the patient and the provider improves mental health treatment adherence.
Researchers have identified a link between complex treatment regimens and poor adherence. Fewer medications and less frequent doses are associated with higher levels of adherence.
For example, a 2001 study found that 79% of participants stuck with their once-daily medication regimen. That percentage steadily decreased as the number of doses increased. Only about half (51%) of the participants adhered to a four-times-a-day schedule.
Another study focusing on hypertension treatment reported an adherence rate of 91% for once-daily medications. In contrast, the adherence rate was 83% among those who took their medicine at least three times a day.
Studies also suggest that a smaller number of pills and shorter treatments (six months or less) tend to promote adherence.
People can’t adhere to treatment programs they can’t afford, nor can they attend appointments or pick up prescriptions when they lack transportation. These limiting factors may be obvious, but studies point to a more surprising socio-economic barrier: lack of social support.
This support can take many forms, including direct family involvement, peer support groups, and community-based support. The healthcare system itself can be a form of social support when people have good relationships with their providers.
Stigma is another social factor that can prevent people from following through with health treatments. Stigma associated with diabetes can lower people’s self-esteem and prevent them from monitoring their blood glucose or taking insulin as prescribed. Experts say mental health stigma interferes with treatment adherence and overall recovery. AIDS, obesity, epilepsy, autism, and even cancer are also frequently stigmatized.
Adherence is a team effort between healthcare providers, patients, and social supports. Let’s take a closer look at some strategies and tech integrations that can improve adherence.
Phase 1
For patients, adherence starts with finding the right provider. Insurance, out-of-pocket costs, location, and availability tend to narrow the options. Within those constraints, it’s important to find someone who listens to you, empathizes with you, and makes you feel comfortable enough to ask questions or disagree.
Phase 2
Once you’ve partnered with a good provider, the next step is to make sure you get the most out of your appointments.
If you can, take notes on your phone or bring a pen and paper. If it’s hard to follow a conversation, think of questions, and take notes at the same time, try these alternatives:
During the appointment, check your understanding by repeating the instructions back to your provider. They can quickly clarify anything you may have misunderstood.
If you agree to a treatment plan but start to have second thoughts after the appointment, message or call your as soon as possible so you can ask more questions or discuss alternatives.
Phase 3
The next phase of a patient-powered adherence plan is all about follow-through. At this point, you should be on board with the treatment plan, and the biggest barriers are likely to be forgetfulness, accessibility, and finances.
There are many tricks and gadgets that can help you remember to do something.
Accessibility issues often involve limited transportation or incompatible schedules, but there can also be health-related barriers like limited dexterity. Here are some ideas:
Finances can be a huge issue, especially for people who don’t have insurance. Using an online discount pharmacies like Cost Plus Drugs may help you get medications and supplies at a reasonable price. Prescription discount cards and manufacturers’ patient assistance programs are also worth looking into. Your provider may also have some cost-cutting tricks up their sleeves, like prescribing medications in 90-day doses, splitting pills, or switching to a more affordable alternative.
Providers, you may feel like adherence is out of your hands, but that’s not true—you do have some influence.
Because many people have poor health literacy and tend to forget instructions after they leave your office, it’s important to have good communication skills.
Patients are also more likely to commit to their treatment plan when they trust their provider. Make sure you practice good bedside manner:
Because simpler treatment plans are associated with better adherence, be mindful when working with someone who takes multiple medications or needs to do something more than twice a day.
Follow-up engagement is another key component to increasing adherence as a provider. It needs to be timely, personal, and goal-oriented, among other factors. Engagement will be the subject of the next article in our series, so stay tuned.
We can all help our friends and family with adherence—with their permission, of course. This may include:
There are also at least two systems in place that affect adherence: the medical system and society at large.
More affordable care, more in-network providers, more coverage for telehealth, and more local clinics could potentially increase adherence by improving accessibility and allowing for the continuity of care. Adherence can also be traced back to seemingly disparate factors, like the public transportation systems people use to get to their appointments. Socioeconomic factors can’t be ignored when looking at the bigger picture.
In addition, medical groups’ processes and procedures can unintentionally hinder providers’ efforts to improve adherence. We’ll look at a technology example in a moment.
The strategies described above are good stop-gap measures—they can be implemented immediately, but they’re not necessarily the most effective end goal. To dramatically improve adherence, we may need a brand-new approach that puts patients first and solves their needs.
In other words, we need to follow the principles of human-centered design, which include:
Here are a few examples of how it’s already being done.
Oral hygiene is an adherence nightmare. Even though there are plenty of good reasons to brush our teeth twice a day, about 50% of us don’t do it. It’s even tougher to get kids to brush their teeth. And when we do pick up a toothbrush, we’re not necessarily using the best plaque-busting techniques, giving all of our teeth equal attention, or brushing for the right amount of time.
Enter the automatic toothbrush. Popularized by brands like Autobrush and Sonic Brush, these u-shaped, battery-powered devices surround your teeth with moving bristles. You need to move the toothbrush side to side for best results, but that’s all there is to it. A built-in timer dings after 30 seconds. Flip the toothbrush around, repeat on the bottom teeth, and you’re done.
This simple routine removes plaque nearly 27 times better than a standard toothbrush and incentivizes kids with fun designs and music. It even improves adherence in adults by being easy to use and more effective than traditional brushing.
“Adherence isn’t just about reminders or incentives—it’s about designing experiences that seamlessly fit into people’s lives,” says Kristine Howell, founder and principal UX strategist at Oliven Labs. “When we apply human-centered design, we remove friction, simplify choices, and make the right behaviors the easiest ones.”
Medication adherence starts when a patient collects their prescription from the pharmacy. But this might not happen for several reasons, like high out-of-pocket costs, difficulty getting to the pharmacy, or a reluctance to take the medicine due to concerns about side effects.
Imagine if a healthcare provider knew their patient never got the prescription. Better yet, imagine they found out as soon as the prescription was restocked—which usually happens in five to seven days. It would pave the way for a timely intervention, like a simple phone call to soothe fears, troubleshoot logistics, or discuss an alternative treatment.
That’s exactly the kind of proactive solution offered by SureScript’s Medication History for Populations. In one case study, Baptist Health Louisville’s Chief Pharmacy Officer, Nilesh Desai, says this approach has helped improve patients’ medication adherence and ease their administrative burdens. “If I call a patient on Wednesday, by Monday I’ll know if the prescription was filled,” Desai said.
For people with diabetes, monitoring blood sugar levels is a critical part of their daily routine, but it’s not exactly fun. One study found that 30% of people with diabetes feel anxious about pricking their fingers. This fear caused some of the participants to avoid testing their blood sugar—a habit that could lead to dangerous conditions like hyperglycemia, hypoglycemia, and diabetic coma.
Continuous glucose monitors (CGMs) like Dexcom improve adherence by reducing the amount of work the patient has to do. Instead of pricking their fingers once or twice per day, they can prick their arm once every ten days. And there are more benefits that appeal to users, like readings every five minutes and low or high alerts.
There’s a tremendous opportunity to design (or redesign) tools, procedures, systems, and other digital innovations to boost healthcare compliance. Potential payoffs include healthier and happier patients, less wasteful spending, and greater control over communicable diseases.
What would your ideal tool or system look like? Put our designers on the case—contact Oliven Labs to schedule a spec call.
In Part 2 of this series, we’ll explore several strategies for improving healthcare literacy through patient engagement. Stay tuned.
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