Concordance, adherence and compliance in medicine taking

Concordance, adherence
and compliance in
medicine taking
Report for the National Co-ordinating
Centre for NHS Service Delivery and
Organisation R & D (NCCSDO)

December 2005
The report authors and core project team were:
Rob Horne
Centre for Health Care Research University of Brighton
John Weinman
Institute of Psychiatry, King’s College London
Nick Barber
School of Pharmacy, University of London
Rachel Elliott
School of Pharmacy and Pharmaceutical Sciences,
University of Manchester
Myfanwy Morgan
Department of Public Health Sciences, King’s College
London

Contributing co-authors:
Professor Alan Cribb, Professor of Bioethics and
Education, King’s College London (Chapter 5)
Dr Ian Kellar, Research Fellow, Centre for Health Care
Research, University of Brighton (Chapter 6 and related
Appendices)
Address for correspondence:
Professor Rob Horne
Centre for Health Care Research
University of Brighton, Falmer, Brighton BN1 9PH
E-mail: r.horne@bton.ac.uk
Telephone: 01273 643985 Fax: 01273 643986

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Executive Summary
Rob Horne, John Weinman, Nick Barber, Rachel Elliott,
Myfanwy Morgan, Alan Cribb & Ian Kellar
This report is a product of a scoping exercise commissioned
by the NHS National Coordinating Centre for Service
Delivery and Organisation (NCCSDO) with the following
aims:
1 Summarise current knowledge about the determinants
of medication-taking.
2 Construct a conceptual map of the area of compliance,
adherence and concordance.
3 Identify priorities for future research of relevance to the
NHS, with particular emphasis on identifying what new
knowledge is needed to be able to develop effective,
realisable, efficient and equitable interventions to
promote the appropriate use of medicines for the
benefit of patients and the NHS.
The scoping exercise involved analysis of the literature, a
listening exercise involving consultation with both a user
group and with a group of academics, health care
professionals and managers, plus feedback from an Expert
Panel.

Main findings and take home messages

Nonadherence to appropriately prescribed medicines is a
global health problem of major relevance to the National
Health Service (NHS).
Nonadherence prevents patients from gaining access to the
best treatment, and this may be particularly problematic in
chronic medical conditions, including current NHS priorities
such as mental health, cancer, diabetes and respiratory
illness.We agree that: ‘Increasing the effectiveness of
adherence interventions may have a far greater impact on
the health of the population than any improvement in
specific medical treatments’.1 The NHS should take action
but requires quality research to guide and evaluate this.

1 Haynes, R., McDonald, H., Garg, A., & Montague, P. (2002). Interventions for
helping patients to follow prescriptions for medications. The Cochrane Database
of Systematic Reviews, 2, CD000011.

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The challenges for research in medication adherence are

similar to those for other health-related behaviours, such as
smoking cessation, exercise and diet: how to influence and
change behaviour.
Our review offers clear insights into not only why previous
interventions have failed, but also how we can improve the
content, development and testing of new approaches.
We recommend that the NCCSDO commissions a coherent
programme of research to inform the development of
effective, patient-centred interventions to facilitate informed
choice and optimal adherence to appropriate prescriptions
where adherence matters most.
The time is right to address this agenda as there is a strong
coherence with the concept of a patient-led NHS and related
policy developments, such as the expert patient programme
and medicines usage review.

Why this scoping exercise is necessary

The prescription of a medicine is one of the most common
interventions in healthcare. In England there were 686
million NHS prescriptions dispensed in 2004, costing £8
billion. The optimal use of appropriately prescribed
medicines is vital to the self-management of most chronic
illnesses including those designated as NHS priorities.
Reviews conducted across disease states and countries are
consistent in estimating that between 30 and 50 per cent of
prescribed medication is not taken as recommended.
This represents a failure to translate the technological
benefits of new medicines into health gain for individuals.
There are potential losses for patients, the NHS and
pharmaceutical industries.
Nonadherence is often a hidden problem: undisclosed by
patients and unrecognised by prescribers.
There is no evidence that the problem of nonadherence has
been solved by recent advances in the design and
presentation of medicines or by the evolution of healthcare
services that have tended to become more ‘patient-centred.’
There is a pressing need to develop effective strategies to
make the delivery of healthcare more efficient and
responsive to patients’ needs by addressing the problem of
nonadherence.

A conceptual map and research agenda

The size and scope of the literature on medication-taking
can make it difficult for practitioners to find their way
around. The complexity of the topic is illustrated by the fact

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that there are at least three terms in common usage:

compliance, adherence and concordance.
This document does not involve an exhaustive review of the
primary literature – this has already been researched to
good effect and is beyond the scope and timescale of the
project. Rather it provides a conceptual map to guide policy-
makers, clinicians and health services researchers through
this complex field. The conceptual map has two elements:
An explanation of the concepts of compliance, adherence
and concordance and recommendations for use of
terminology.
A summary of current knowledge about the factors
influencing medication-taking and how these might be
influenced.

Terminology – compliance, adherence

and concordance
Compliance is defined as: ‘The extent to which the patient’s
behaviour matches the prescriber’s recommendations.’
However, its use is declining as it implies lack of patient
involvement.
Adherence is defined as:‘The extent to which the patient’s
behaviour matches agreed recommendations from the
prescriber.’ It has been adopted by many as an alternative
to compliance, in an attempt to emphasise that the patient
is free to decide whether to adhere to the doctor’s
recommendations and that failure to do so should not be a
reason to blame the patient. Adherence develops the
definition of compliance by emphasising the need for
agreement.
Concordance is a relatively recent term, predominantly used
in the United Kingdom (UK). Its definition has changed over
time from one which focused on the consultation process, in
which doctor and patient agree therapeutic decisions that
incorporate their respective views, to a wider concept which
stretches from prescribing communication to patient support
in medicine taking. Concordance is sometimes used,
incorrectly, as a synonym for adherence.
It can be seen that these terms are related but different.
Two issues underpin this. First, whether patients should take
their medicines or not depends on whether the prescribing
was appropriate – we do not want to promote patients
taking inappropriate medicines. Hence all terms refer back in
varying degrees to the act of prescribing. Second, all these
terms involve varying normative agendas – understandings
of what is good and right about prescribing and medicine
taking; we explore these concepts in Chapter 5.

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Terminology recommendations
We recognised that these three terms are now used
interchangeably and that this has generated some confusion.
After discussion within the Project team and with our Expert
Panel and Consultation Groups, we recommend ‘adherence’
as the term of choice to describe patients’ medicine taking
behaviour.
We recognise that adherence is not always a ‘good thing’ as
a prescription may be inappropriate or not reflect the
patients’ changing needs. We assume that adherence is
appropriate and beneficial if it follows a process that allows
patients to influence the decision making if they wish, and
an appropriate choice of medicine is made by the prescriber.

Determinants of medication-taking
behaviour
We grouped the literature on adherence into four core
themes: explaining patient behaviour: patient-provider
interactions; societal policy and practice; and interventions.
These are underpinned by complex notions of the various,
and sometimes conflicting, things we consider to be ‘good’
about prescribing and medicine taking. We pause to explore
these issues in between the policy and intervention themes.
Medicine-taking needs to be understood as a variable
behaviour, which occurs within, and is influenced by,
external, environmental factors including interactions with
healthcare providers and by the wider context of societal-
policies and practice. Theme four spans these domains as
interventions to facilitate optimum medicine-taking can be
targeted at one or more of these domains. Below we present
a résumé of current knowledge and key outstanding
research questions for each them. The research agenda as it
relates to SDO research priorities is presented at the end of
this Executive Summary.

Theme 1: Explaining medication-taking

behaviour
The research evidence shows that variation in adherence
cannot be explained by a range of fixed factors, such as the
type or severity of disease; sociodemographic variables or
personality traits. Adherence is positively correlated with
income when the patient is paying for treatment but not with
general socio-economic status. Furthermore, providing clear
information, although essential, is not enough to guarantee
adherence. Nonadherence is often lower for more complex
regimens, but significant nonadherence remains when the
frequency of dosing is reduced. Depression, but not anxiety,
is related to nonadherence to medication prescribed for
conditions other than depression.

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The main development in adherence-related research over

the past decade has been an increasing recognition of the
importance of patients ‘common-sense’ beliefs about their
illness and treatment as determinants of adherence. This
work shows that, although nonadherence may be puzzling or
frustrating from the prescribers’ perspective, viewed from
the patient’s perspective, it often represents a logical
response to the illness and treatment in terms of their own
perceptions, experiences and priorities, including concerns
about side effects and other unwelcome effects of medicines.
Patients therefore seek to balance perceived necessity and
concerns and to minimise their use of prescribed medicines.
We endorse an approach to nonadherence that
acknowledges patients’ own beliefs and active decision-
making but also recognises the constraints and practical
barriers that reduce people’s ability to take medicines as
prescribed. Nonadherence is therefore best seen as variable
behaviour with intentional and unintentional causes.
Unintentional nonadherence arises from capacity and
resource limitations that prevent patients from implementing
their decisions to follow treatment recommendations and
involves individual constraints (eg, memory, dexterity, etc)
and aspects of their environment (eg, problems of accessing
prescriptions, cost of medicines, competing demands, etc).
Intentional nonadherence arises from the beliefs, attitudes
and expectations that influence patients’ motivation to begin
and persist with the treatment regimen.
Research to date gives a good indication of the factors
influencing intentions and constraints but we know little
about the extent of intentional versus unintentional
nonadherence or their interrelationships. Internal factors
such as motivation and capacity may be moderated by
external factors, such as the quality of communication
between the patient and healthcare provider, as discussed in
Theme two (Chapter 3), and by the wider societal contexts,
such as access to resources and societal policy and practice,
as outlined in Theme three (Chapter 4).
Most research has been cross-sectional whereas adherence
is a dynamic process that may change over time and needs
to be followed-up. We now need longitudinal studies to
investigate how patients’ choices and adherence behaviours
change over time and how they might be influenced by
interventions. There is a particular need to examine
intentional and unintentional influences in vulnerable groups,
such as children, adolescents and the elderly, as well as
vulnerable groups defined by social exclusion or other
factors, such as ethnicity. We also need to include how
patients judge their personal need for medication in different
situations and stages of illness.

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Theme 2: Patient-provider interactions

and communication in healthcare
Our review of the empirical evidence identified surprisingly
few studies that systematically evaluate the direct effects of
the prescribing consultation on medication adherence
behaviour. Further basic research is needed to clarify the
effects of the consultation on medication adherence, the
extent to which consultation skills training can improve
adherence, and how different messages from different
sources influence patients’ medication-taking behaviour.
We know little about how physicians’ beliefs influence the
process and content of prescribing and this is a priority for
further research. We also need to know more about how we
can equip prescribers (and their patients) to deal with the
cognitive and emotional challenges of working in partnership
to achieve appropriate prescribing, and optimal adherence.
This is a key challenge for NHS workforce development,
especially as new prescribers (such as nurses and
pharmacists) come ‘on-line’. We need concomitant research
on how prescribers can most efficiently support patient
informed choice and optimal adherence both individually and
as part of a multidisciplinary team.

Theme 3: Societal policies and practice

The impact of nonadherence at a societal level is probably
substantial, but existing data in the UK are too poor to fully
characterise this, possibly because, until recently, the
management of adherence has not featured strongly in NHS
policy. However, several core policy initiatives such as the
Expert Patient programme, National Service Frameworks and
Medicines Use Reviews (MURs) now place patient self-
management and involvement in decisions at the forefront of
healthcare delivery. These offer strong incentives and
provide an excellent context for the development of
interventions to help patients with long term illnesses to get
the best from medicines. However, research is needed to
inform their development and assess their impact on the
medication needs and practices of patients and their carers.
Key policies that are predicted to affect medicines-taking
behaviour are the prescription tax system, deregulation of
prescription only medicines and expansion of prescribing
rights. The accelerated rate of deregulation of medicines in
the UK needs to be assessed: does use of medicines change
and is this change in use appropriate or inappropriate? Does
deregulation lead to financial barriers that reduce use in
some groups? The recent introduction of supplementary and
independent prescribing rights for non-medical prescribers
has generally been welcomed by health professional groups.
However, it is not clear whether patients will perceive this
development as a welcome or confusing plurality of service
provision, or whether or not it will improve medicines-taking
behaviour.

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Doing the right thing: the normative theme

Underpinning this whole report are two questions – what is
good prescribing and what is good medicine taking? These
questions, in contrast to questions of effectiveness, have
had little in depth exploration in the literature, yet they must
be addressed to inform policies and practices. We found
these questions to be relevant across each of our four
themes and devoted a separate chapter of the report
(Chapter 5) to explore this normative agenda (questions of
what is right and good). These questions are complex. For
example, in Chapter 5 we identify a dozen values around
these areas which can be legitimately held, yet there is little
exploration of how patients and prescribers should deal with
situations in which the values conflict. There is a need for
more work in this area to support patients and prescribers in
their practice.
Questions about ‘good’ and ‘right’ are normative questions;
they need to be addressed partly by philosophical argument
and partly by empirical research. In particular, work is
needed on joint decision making. What is the ideal nature of
communication? What sort(s) of reasoning should be used
so that the decision is truly ‘joint’? Which forms of joint
decision making are possible and what are their strengths
and weaknesses? Linked to this is the important research
question of the effect of different forms of accountability on
patient and prescriber. Currently decision making may be
joint but accountability is with the prescriber; this limits the
potential for patients to influence a decision. Research is
needed into the practical and psychological implications of
increasing patient accountability in line with their
responsibility for the prescribing decision.

Theme 4: Interventions to facilitate

adherence
The literature on adherence interventions has been the
subject of three major systematic reviews over the past five
years, culminating in a Cochrane systematic review in 2002.
As part of our scoping exercise we extended the scope of the
Cochrane review by including studies that met the stringent
quality criteria, but were not eligible for inclusion in the
Cochrane review because they had measured adherence but
not clinical outcome. We do not dispute the Cochrane
reviewers’ rationale that improving adherence is only
valuable if it brings clinical benefits to the patient. However,
we wanted to examine whether including studies that had
measured adherence (but not clinical outcome) might
provide valuable information about how to change

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adherence behaviours.2 Our analysis of the findings of

previous systematic reviews, including our extension of the
Haynes review, can be summarised as:
1 Interventions to promote adherence are broadly
efficacious. However, the effects were generally modest
We know that adherence can be increased, but there is
considerable room for improvement.
2 Few interventions have been systematically developed,
using appropriate theoretical models, nor have they
been modelled and piloted with assessment of process
variables as well as outcomes (as recommended in the
MRC framework for complex interventions to effect
behaviour change). Consequently, it is difficult to tell
why some interventions work and others do not.
3 Comprehensive interventions that combined approaches
were typically more effective than interventions focusing
on single causes of nonadherence. However, few
interventions could be described as ‘patient-centred’ as
they did not individualise the approach to match
patients’ needs and preferences.

Research priorities
Because medicines carry the potential for harm as well as
benefit we have identified a normative agenda to address
questions of what is good-prescribing and good medicine-
taking and an empirical research agenda to address how
adherence might be improved. In an ideal world the
normative agenda would come first and inform the empirical
agenda, however, realistically both need to be pursued in
parallel.
There is an imperative to move ahead with the empirical
agenda in conditions where there is strong supporting
evidence for the benefits of medication and importance of
adherence. This is particularly relevant for the NHS SDO
programme as the prescription of a medicine is one of the
most common and, therefore, costly medical interventions.
Optimising use of prescription medicines is a key priority for
the delivery and organisation of healthcare.

2 There have been no large scale systematic reviews of the intervention

literature since 2003. It is possible that more effective interventions may have
emerged since then. However, neither the Project Team nor our Consultation
Groups and Expert Panel were aware of a significant body of studies to
contradict our analysis of the interventions literature, based on published
systematic reviews.

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The empirical research agenda

The main research priority is the development of effective,
efficient, realisable and equitable interventions to facilitate
adherence to appropriate prescriptions3 where adherence
matters most. These can be defined as:
1 Conditions where there is strong evidence supporting
the benefits of medication, above other treatment
options and over doing nothing.
2 Treatments where there is strong evidence that high
levels of adherence are essential to ensure efficacy or
prevent problems such as the emergence of treatment-
resistance.
Although more work is needed to develop a framework for
adherence priorities, we can immediately identify examples
that seem to fit the criteria. These might include: highly
active anti-retroviral therapy for HIV, pharmacological
treatment of diabetes, immunosuppressant medication
following transplantation, preventer medication in asthma,
medicines for severe mental illness, preventative medicine
for cardiovascular disease, anti-tuberculosis treatment and
anti-cancer agents.
In this scoping exercise we grouped the literature on
adherence into core themes: explaining patient behaviour,
patient-provider interactions and societal policy and practice,
all of which are relevant to our forth theme, the
development of interventions. Our review of the literature
identified existing knowledge and outstanding research
questions within each of the themes that can inform the
development of innovative interventions to facilitate optimal
adherence to appropriate medicines.
Our analysis of the literature on the causes of nonadherence
and our assessment of the reasons for the limited success of
interventions provide clear pointers to improving content,
development and testing of interventions. The main lessons
are:
Content Interventions should be tailored to meet the needs
of patients taking account of the particular perceptual (eg,
beliefs and preferences) and practical (eg, capacity and
resources) factors influencing intentional and unintentional
nonadherence for that individual.

3 How we define an ‘appropriate’ prescription may vary according to individual

circumstances, and this needs to be addressed within a normative research

agenda. However, the essence of appropriate prescribing is the application of
the scientific evidence base to the unique needs and preferences of the
individual, taking account of their desires and capacity for involvement in the
decision.

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Development and testing Interventions should be

developed using an appropriate theoretical framework with a
phased approach to testing that includes assessment of the
process (ie, the things that are targeted for change), as well
as outcomes. The MRC framework for complex interventions
to effect behaviour change may be useful in this respect.4
The fundamental questions that need to be addressed in
order to develop such interventions are:
1 What are the most effective methods for addressing the
cognitive (eg, beliefs; attitudes), emotional and capacity
(eg, memory limitations; changes in routines/habits,
etc) factors, which result in reduced adherence to
appropriate medication?
2 How can we enable prescribers and other members of
the NHS workforce to support patients by facilitating
informed choice and optimal adherence to appropriate
prescriptions?
3 How can we incorporate an awareness of patient needs
in relation to medicines and adherence support into the
organisation and delivery of everyday healthcare to
meet the requirements of NSFs, a patient-led NHS and
the drive for greater efficiency in healthcare delivery?
This research agenda is highly relevant to the NHS SDO
research priorities of patient choice, access and continuity of
care, workforce, e-health, methodological research and
governance.5 We have mapped the key research questions
relating to facilitating informed choice and optimal
adherence to appropriate prescription onto the NHS SDO
priorities in Chapter 7 and at the end of this Executive
Summary.
The normative research agenda
Work is needed on what types of prescribing can be
considered ‘good,’ and what should be considered good
medicine taking. These questions need to be answered in
ways that are deliverable by patients and prescribers, and
underpin the successful implementation of policy in areas
such as the Expert Patient and NSFs. The normative
questions are linked to empirical questions in Chapter 5 to
ensure that realistic, acceptable, achievable answers will
result. While the SDO may wish to fund some of this work
they may also wish to draw the attention of humanities and
social science Research Councils or other funding agencies to
the need for fine grained philosophical work in this area.

4Campbell, M., Fitzpatrick, R., Haines, A., Kinmonth, A. L., Sandercock, P.,

Spiegelhalter, D., et al. (2000). Framework for design and evaluation of

complex interventions to improve health. BMJ, 321 694-696.
5 http://www.sdo.lshtm.ac.uk/commissioninggroups.htm

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Conclusions and Recommendation

1 The evidence from this and previous reviews is that
nonadherence to appropriately prescribed medicines is a
global health problem of major relevance to the NHS.
2 Current levels of nonadherence imply a failure to
address patients’ needs and preferences and represent
a fundamental inefficiency in the delivery and
organisation of the NHS. Nonadherence prevents
patients from gaining access to the best treatment, and
this may be particularly problematic in chronic medical
conditions, including current NHS priorities.
3 We agree with the authors of a recent Cochrane
systematic review that: ‘Increasing the effectiveness of
adherence interventions may have a far greater impact
on the health of the population than any improvement
in specific medical treatments.’6 The NHS should take
action but we require quality research to guide and
evaluate this and the development of novel patient-
centred interventions to facilitate informed choice and
optimal adherence to appropriate prescriptions which is
the overarching priority.
4 The challenges for a research agenda in medication
adherence are similar to those for other health-related
behaviours such as smoking cessation, exercise and
diet: how to influence and change behaviour.
5 Although previous interventions to facilitate adherence
have met with only limited success, it would be a
mistake to interpret this as an indication that
intervention is likely to be futile. On the contrary, our
review offers clear insights into, not only why previous
interventions have failed, but also how we can improve
the content, development and testing of new
approaches. This includes work on the ideal types of
patient-prescriber relationship and roles of the patient
and prescriber during medicine taking.
6 This report sets out the key research questions that
need to be addressed to enable us to do this and these
map onto the NHS SDO research priorities.
7 We recommend that the NCCSDO commissions a
coherent programme of research to inform the
development of effective, patient-centred interventions
to facilitate informed choice and optimal adherence to
appropriate prescriptions where adherence matters
most. This programme is essential to guide the delivery
of recommendations for medicines use within NHS NSFs

6 Haynes, R, McDonald, H, Garg, A, and Montague, P. 2002. `Interventions for

helping patients to follow prescriptions for medications’, The Cochrane Database

of Systematic Reviews, 2, CD000011.

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and address a fundamental inefficiency in healthcare

delivery. The potential benefits are likely to include:
better care tailored to patient needs, higher rates of
adherence to appropriate medication, fewer unwanted
and unused prescriptions, more effective management
of chronic illness, increased patient safety and
satisfaction and fewer emergency admissions. The time
is right to address this agenda as there is a strong
coherence with the concept of a patient-led NHS and
related policy developments, such as the expert patient
programme and medicines usage review.

Mapping research questions onto the

SDO research priorities
Key research questions mapped onto SDO research priority
areas

Patient choice 7

1 In what ways can and should patients’ initial choices

and preferences be modified?
2 In what ways and under what circumstances should
patient choice form the basis for decision making in
prescribing and medicine-taking?
3 What are most effective ways of representing evidence
for the likely benefits and risks of medication?
4 How can we tailor medicines information to match the
requirements of individual patients and their carers?
5 Where patients’ decisions are based on misplaced
beliefs or misconceptions about the illness and
treatment, how and when should this be addressed?
6 How can we help people make ‘informed choices’ about
adherence to prescribed medication?
7 How should we communicate and deal with uncertainty
within prescribing-relating consultations?
8 How can professional and lay accountability be best
aligned to support patient choice?
9 How do patient preferences for involvement in
medication-related decisions vary and how should
prescribers responds to this?
10 How do patients’ perceptions, preferences, choices and
medication-taking behaviour change over time in

7 CARERS – Many of the questions that are relevant to patient choice and

support will also apply to patients’ carers and there is scope for synergy and
continuity with the SDO Programme on carers.

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conditions where adherence to medication matters

most?

Access and continuity of care

11 How can we help patients to overcome the capacity and
resource limitations preventing access to effective
healthcare?
12 How can we address and identify misconceptions about
illness and treatment that prevent access to appropriate
medication

Workforce
13 How can we equip prescribers (and their patients) to
deal with the cognitive and emotional challenges of
working in partnership to achieve informed choice and
optimal adherence to appropriately prescribed
medicines, where adherence matters most?
14 How can adherence review and adherence support be
incorporated into medication-usage review in a way that
promotes informed choice and supports adherence to
agreed, appropriate prescriptions?
15 What are patients’ perceptions and behavioural
reactions to new prescribers (eg, nurses and
pharmacists)?
16 What are the barriers to effective and efficient multi
disciplinary approaches to appropriate prescribing and
adherence support? How can these be overcome?
17 How can we enable new and existing prescribers to
identify patients who are priority for medication-review
and adherence support?
18 How can we support prescribers to meet the challenges
of quality frameworks relating to medication-usage as a
component of self-management?
19 In what ways is it possible to supplement the activities
of the NHS workforce in facilitating optimal mediation
usage through other, complimentary approaches (eg,
the use of ‘expert patients’, family support, etc).

e-Health
20 How can technological developments (eg, computers,
mobile telephones, etc) be utilised to provide ongoing
support for informed choice and adherence to agreed
prescriptions?
21 How can we develop and apply effective ‘technologies’
to facilitate behaviour-change to achieve optimal
adherence to appropriate and agreed prescriptions?
Here technologies may be ‘talk treatments,’ such as
cognitive behaviour approaches.

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Methodologies
22 How can we facilitate the honest disclosure of
medication-taking behaviours within prescribing-related
consultations and medication use reviews? How can we
equip health practitioners to respond appropriately and
effectively?
23 What are the alternatives to full-scale Randomised
Controlled Trials (RCTs) that can be used to conduct
preliminary evaluations of the components of
interventions to support informed choice and
adherence? (corresponding to MRC Phases 1 and 2)
24 How can existing validated methods for assessing
adherence-related perceptions and adherence
behaviours be adapted for routine use in the NHS?
25 How can we enable new and existing prescribers to
identify patients at risk of nonadherence or who are a
priority for medication-review and adherence support
and how can we provide it – new methods, new
practitioners (eg, health trainers)?
26 How should we operationalise ‘informed choice’ in
relation to medications taking?

Governance
27 How do differences in the arrangements existing in
England, Wales and Scotland, such as the role of
prescription charges, affect prescription filling for
essential and non-essential medicines, subsequent
patient health, present and future health service and
societal cost?

Adherence in vulnerable groups

Consideration of vulnerable groups cuts across the
explanatory themes and is relevant for most research
questions, regardless of whether research is targeted at
explaining individual behaviour, investigating communication
in healthcare, societal policy and practice or evaluating
interventions. Work in this area requires systematic reviews
of the available literature followed by empirical studies.
Specific questions are:
1 What are the effects of social disadvantage and
ethnicity on accessing prescriptions and adherence to
prescribed medication?
2 How do the perceptions and life circumstances of
different age groups (children, young adults, elderly
people) influence adherence and what are the
implications for interventions?
3 What are the particular barriers to medicines use for
people with multiple pathologies (and their informal
carers) and what interventions are required?

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Disclaimer

This report presents independent research commissioned by the National

Institute for Health Research (NIHR). The views and opinions expressed
therein are those of the authors and do not necessarily reflect those of the
NHS, the NIHR, the SDO programme or the Department of Health

Addendum

This document was published by the National Coordinating Centre for the
Service Delivery and Organisation (NCCSDO) research programme,
managed by the London School of Hygiene and Tropical Medicine.

The management of the Service Delivery and Organisation (SDO)

programme has now transferred to the National Institute for Health
Research Evaluations, Trials and Studies Coordinating Centre (NETSCC)
based at the University of Southampton. Prior to April 2009, NETSCC had
no involvement in the commissioning or production of this document and
therefore we may not be able to comment on the background or technical
detail of this document. Should you have any queries please contact
sdo@southampton.ac.uk