SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
August, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF
The potential benefits of effective medications may not always be achieved if patients do not take them as prescribed. Adherence is defined as the extent to which a patient follows the instructions given for a prescribed treatment. Many adherence interventions are intended to assist patients with completing this task.
Key messages
- Adherence interventions may be difficult to implement in low-income countries where health systems face greater challenges.
Clinicians and people making decisions concerning the implementation of interventions aimed to improve medication adherence.
Haynes RB, Ackloo E, Sahota N, et al. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000011.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Poor adherence reduces treatment benefits when treatment responses depend on following a therapy dosage and schedule. This is a problem given that low adherence to prescribed treatments is very common. Non-adherence may have numerous causes, including problems with a regimen (e.g. adverse effects), poor instructions, poor provider-patient relationships, poor patient memory, patients contesting the need to be treated, or the inability of patients to pay for treatment.
Given the multi-faceted dimension of poor adherence, a range of possible interventions can be used, such as providing more instructions for patients, counselling and patient empowerment, automated telephone or computer-assisted patient monitoring, manual telephone follow-ups, family interventions, ways to increase the convenience of care, simplified dosing, involvement of patients in self-monitoring, reminders, alternative methods of pill packaging, dose-dispensing units of medication and medication charts, reinforcements or rewards, different medication formulations, crisis intervention (e.g. for attempted suicide), direct observation of treatments, lay health mentoring, augmented pharmacy services, psychological therapy, mailed communications and group meetings.
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Review objectives: To summarise the effects of interventions to help patients follow prescriptions for medications. |
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| Types of | What the review authors searched for | What the review authors found |
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Study designs & interventions |
Randomised trials evaluating interventions to improve adherence with prescribed, self-administered medications. |
78 trials evaluating 93 diverse interventions. |
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Participants |
Patients who were prescribed medication for a medical disorder (including psychiatric), but not for addictions. |
Patients with several different chronic conditions including hypertension (12 studies), schizophrenia or acute psychosis (10), asthma or chronic obstructive pulmonary disease (COPD) (11), rheumatoid arthritis (2), hyperlipidaemia (3), depression (4) and HIV (12). |
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Settings |
Any setting. |
Many different settings and venues were included. Trials were conducted in the USA (30 studies), UK (14), Spain (5), Canada (8), Australia (3), the Netherlands (3), China (3), France (2), Mexico (1), Norway (1), Italy (1), Sweden (1), Ghana (1), Denmark (1), Republic of Ireland (1), United Arab Emirates (1), Switzerland (1) and Malaysia (1). |
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Outcomes |
Medication adherence and patient outcomes. |
9 studies on short-term and 71 on long-term treatments measuring adherence and patient outcomes. |
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Date of most recent search: February 2007. |
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Limitations: This is a systematic review with moderate limitations related to how the results were synthesized. |
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Haynes RB, Ackloo E, Sahota N, et al. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000011.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
An update of this review, published in 2014, included 109 new randomized trials, bringing the total number of included studies to 182. The interventions differed widely and the authors did not classify studies according to the type of intervention. Instead, a narrative focused on the results of 17 studies with low-risk of bias and a database of the 182 studies (without any synthesis of the findings) was provided. We therefore have not prepared a SUPPORT Summary of the updated review. Only five of the studies in the updated review found an improvement in both medicine adherence and clinical outcomes, and no common characteristics for their success could be identified. Overall, even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.
This previous review found 78 studies conducted in many different settings, most of which were in high-income countries. Nine studies addressed interventions to improve adherence to short-term treatments, and 71 to long-term treaments. The studies evaluated very different types of interventions.
1) Interventions to improve adherence to short-term treatments
Nine studies evaluated 10 different interventions to increase adherence in very diverse conditions. The interventions evaluated were: the provision of more detailed instructions to patients (4 studies), the use of dose-dispensing units of medication (1), counselling about the target disease of the patients (3), the use of different medication formulations (1) and augmented pharmacy services (1)
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Interventions to improve adherence to short-term treatments |
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People: Patients with several different medical conditions. |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
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Adherence |
Several quite simple interventions increased adherence, but the effects were inconsistent across the studies. Fewer than half of the interventions showed benefits. |
Very Low |
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Patient outcomes |
Several quite simple interventions improved patient outcomes, but effects were inconsistent across the studies. Fewer than half of the interventions showed benefits. |
Very Low |
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| GRADE: GRADE Working Group grades of evidence (see above and last page). | ||||
2) Interventions to improve adherence to long-term treatments (more than 6 months)
71 studies evaluated 81 different interventions to increase adherence in very diverse conditions, including: asthma and chronic obstructive pulmonary disease (12 studies), hypertension (12), diabetes (6), HIV (12), rheumatoid arthritis (2), dyslipidemia (5), mental health conditions (14), epilepsy (1), heart failure (1) and ischemic heart disease (1). Some studies focused on specific medications, such as oral anticoagulant therapy (1) and contraception (1). Two studies evaluated interventions to increase adherence to complex regimens in the elderly.
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Interventions to improve adherence to long-term treatments |
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People: Patients with several different conditions. |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
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Adherence |
Only 34 of 81 interventions were associated with improvements in adherence. Almost all of the interventions that were effective were complex and included combinations of: more convenient care, information, reminders, changing dosing schedules, self-monitoring, reinforcement, counselling, family therapy, psychological therapy, crisis intervention, manual telephone follow-ups, and supportive care. Even the most effective interventions did not lead to large improvements in adherence. |
Low |
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Patient outcomes |
Only 26 of 81 interventions led to improvement in at least one patient outcome. Almost all of the interventions that were effective were complex and included combinations of: more convenient care, information, reminders, changing dosing schedule, self-monitoring, reinforcement, counselling, family therapy, psychological therapy, crisis intervention, manual telephone follow-ups, and supportive care. Even the most effective interventions did not lead to large improvements in patient outcomes. |
Very Low |
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| GRADE: GRADE Working Group grades of evidence (see above and last page). | ||||
| Findings | Interpretation* |
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| APPLICABILITY | |
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| EQUITY | |
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The studies did not directly address the issue of equity. |
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| ECONOMIC CONSIDERATIONS | |
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The included studies provide no data about the cost of the interventions. |
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| MONITORING & EVALUATION | |
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| *Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.supportsummaries.org/methods | |
Related literature
Nieuwlaat R, Wilczynski N, Navarro T, et al. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD000011.
Horne R, Weinman J, Barber N, et al. Concordance, adherence and compliance in medicine taking: a scoping exercise. London: NCCSDO; 2005.
Schroeder K, Fahey T, Ebrahim S. Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD004804.
Vermeire EIJJ, Wens J, Van Royen P, et al. Interventions for improving adherence to treatment recommendations in people with type 2 diabetes mellitus. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD003638.
Volmink J, Garner P. Directly observed therapy for treating tuberculosis. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD003343.
Schedlbauer A, Davies P, Fahey T. Interventions to improve adherence to lipid lowering medication. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD004371.
Schedlbauer A, Davies P, Fahey T. Interventions to improve adherence to lipid lowering medication. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD004371.
Mahtani KR, Heneghan CJ, Glasziou PP, Perera R. Reminder packaging for improving adherence to self-administered long-term medications. Cochrane Database Syst Rev. 2011, Issue 9. Art. No.: :CD005025.
Al-aqeel S, Al-sabhan J. Strategies for improving adherence to antiepileptic drug treatment in patients with epilepsy. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD008312.
This summary was prepared by
Gabriel Rada. Unit for Health Policy and Systems Research, Faculty of Medicine, Pontificia Universidad Católica de Chile
Conflict of interest
None declared. For details, see: www.supportsummaries.org/coi
Acknowledgements
This summary has been peer reviewed by: Brian Haynes, Jimmy Volmink, and Hanna Bergman
This review should be cited as
Haynes RB, Ackloo E, Sahota N, et al. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000011.
The summary should be cited as
Rada G. What are the effects of interventions to improve adherence to medication? A SUPPORT Summary of a systematic review. August 2016. www.supportsummaries.org
Keywords
evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, medication adherence, medication compliance, medication non-compliance, medication non-adherence, patient compliance, treatment refusal.
