Original articleUnderstanding different beliefs held by adherers, unintentional nonadherers, and intentional nonadherers: Application of the Necessity–Concerns Framework☆
Introduction
Nonadherence to medication is a “worldwide problem of striking magnitude” [1]. It can lead to unnecessary ill health for patients and avoidable additional treatment, and it has been proposed that economic consequences could be as much as US$3 billion a year in the United States [2]. Consequently, a plethora of research into why nonadherence occurs exists. As many as 200 factors have been hypothesized to influence adherence [3], [4], and these factors can be classified as either intentional or unintentional. Intentional nonadherence is associated with motivation and patients' beliefs about taking medications. Conversely, unintentional nonadherence is related to patients' skills or their ability to take their medication (e.g., problems with manual dexterity or forgetfulness). There may be overlap between these categories (e.g., people who have a low perceived necessity for their medication may see it as less salient and may be more likely to forget to take it) [5]. Furthermore, patients may report both intentional and unintentional nonadherence to different medications or to the same medication at different times.
Research into patients' beliefs about medicines suggests the utility of the Necessity–Concerns Framework for operationalizing key beliefs that influence adherence [6]. Proponents of the framework argue that people's perceptions of their medication can be categorized as beliefs about the necessity of taking the medication and concerns about taking it. These beliefs, and the way in which individuals balance their concerns against perceptions of necessity, have been found to predict adherence to medication in many different illness groups (e.g., HIV [7], asthma [8], renal disease [9], cancer and coronary heart disease [6], and rheumatoid arthritis [10]).
Existing evidence suggests that certain beliefs about medicines are more predictive of intentional nonadherence than of unintentional nonadherence. In a sample of 173 patients with asthma, intentional nonadherence was most strongly predicted by patients' balance of “pros and cons” of taking the medication [11]. Conversely, unintentional nonadherence was not predicted by this balance of beliefs. The same association was found in a study of 117 patients who were taking antiretroviral medication [12].
However, there are still gaps in our understanding. We need to know whether beliefs about medicines are different between adherers, unintentional nonadherers, and intentional nonadherers at the start of a new treatment for a range of chronic conditions. This information is important because it could highlight targets for early interventions to address nonadherence.
Section snippets
Aim and objectives
The aim of this study was to assess variations in beliefs about medicines between patients who report adherence, patients who report unintentional nonadherence, and patients who report intentional nonadherence to a new medication for a chronic condition.
The objectives of the comparison of these three groups of patients were to:
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Assess whether there was a significant difference in beliefs about the necessity of taking the new medicine
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Assess whether there was a significant difference in concerns
Design
The study from which these data are drawn is part of a larger survey that explores patients' experiences with a newly prescribed medication for a chronic condition. The methods and results of the main study are reported in full elsewhere [13]. In brief, the study was a longitudinal survey of patients' experiences with a new medication for a chronic condition. Data were collected 10 days and 4 weeks after patients started a new medication for a chronic condition, via telephone interviews and
Sample and demographics
Two hundred fifty-eight participants consented to take part in the study. On the Day 10 telephone interview, 239 patients (93%) took part; 19 could not be contacted. One hundred eighty-one patients (70%) returned their postal questionnaire, which was sent immediately afterwards. The demographics of the overall sample are reported elsewhere [13]. However, as this analysis focuses on subcategories of patients who were adherent, unintentionally nonadherent, and intentionally nonadherent, the
Discussion
The results show that just 10 days after starting a new medication for a chronic condition, there were significant differences in beliefs between patients who reported adherence and those who reported intentional nonadherence. Intentional nonadherers were significantly more likely to doubt their personal need for their medication and to have stronger concerns about taking it compared to adherers. Furthermore, patients' balance of beliefs regarding necessity and concerns (the necessity–concerns
Acknowledgments
This work was undertaken with funding received from the Department of Health London, Research and Development, Responsive Funding Program. We would like to thank the pharmacists and patients for their cooperation.
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The views expressed in the publication are those of the authors and not necessarily those of the National Health Service or the Department of Health.