Original article
Understanding different beliefs held by adherers, unintentional nonadherers, and intentional nonadherers: Application of the Necessity–Concerns Framework

https://doi.org/10.1016/j.jpsychores.2007.05.004Get rights and content

Abstract

Objective

The objective of this study was to explore beliefs about medicines, using the Necessity–Concerns Framework, of patients who report adherence, unintentional nonadherence, and intentional nonadherence.

Method

This study performed a cross-sectional survey of patients starting a new medication for a chronic condition. Self-reported adherence was assessed via telephone interview. The Necessity–Concerns Framework was operationalized using the Beliefs About Medicines Questionnaire, which assesses beliefs about the necessity of and concerns with taking medications.

Results

Intentional nonadherers, compared to adherers, had lower perceptions of the necessity of their new medication and higher levels of concerns about taking it. Conversely, unintentional nonadherers were not significantly different from adherers. Intentional nonadherers were more likely to rate their concerns as high relative to their need for treatment than both adherers and unintentional nonadherers.

Conclusion

When patients start a new medication for a chronic condition, intentional nonadherers hold beliefs significantly different from those of adherers and unintentional nonadherers. These findings have implications for practice in helping clinicians to reduce this type of nonadherence.

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:

  • Assess whether there was a significant difference in beliefs about the necessity of taking the new medicine

  • 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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