Issues and Challenges in Medication Compliance

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Issues and Challenges in Medication Compliance For Seniors

Issues and Challenges in Medication Compliance

Anantha Naik Nagappa and Uday Venkat Mateti

Manipal College of Pharmaceutical Sciences, Manipal University, Manipal. KA-576104.

What is Medication Compliance?

Medication Compliance means agreeing to follow the instructions and information given by doctor and pharmacist for using medications. Usually the patients show 100% agreement at the point of severity of disease condition. On the contrary as severity of disease becomes bearable the patient switch their priorities and likely to become non-compliance in the due course of treatment. Unfortunately the patient presumes the reliefs of symptoms due to disease stop and disappears. The disease may still present and remain dormant to reappear with more severity, as the drug to control the disease is stopped abruptly without consulting the doctor or pharmacist.

Why to measure Medication Compliance?

The consequences of poor medication compliance as severe influence an impact not only on patient's individually health but have chain effect on economy, quality of life and public health. For example indiscriminate use of antibiotics and poor compliance is one of the major predictors of development of bacterial resistance the resistance bacteria having capacity to withstand the assault by antibiotics and may cause public health hazard. The completion of full course of prescribed antibiotics is recommended but seldom practiced.

What are the methods to measure Medication Compliance?

Table 1: Methods of Medication Compliance

Direct methods[1]

Indirect methods[1]

Directly observed therapy

Patient questionnaires or self-reports or Patient diaries[2]

Measurement of the level of medicine or metabolite in blood

Pill counts

Measurement of the biologic marker in blood

Frequency of Prescription refills

Assessment of the patient's clinical response

What are challenges in Medication Compliance?

The education and updating knowledge of the patient in way to influence attitudes along with practice is biggest challenge in medication compliance. The other challenges which come in the way of patient compliance include the cost of the therapy and bother some system lags of health care delivery. The poor understanding with inadequate communication regarding drug, disease and life style modification by the health care provider to the patients may be an important factor as well.

What are the strategies to improve the Medication Compliance?

The knowledge, attitude and practice (KAP) seems to be effective as patients engagement can be attempted through it other aspects like forgetfulness, non-availability of medicines can be addressed using reminders and ensuring enough doses of medicines being available with the patients. In case, affordability is the issue can resolved by suggesting generics or philanthropic resources of medicines. The successful adherence-enhancing strategies are SIMPLE.

The word SIMPLE includes

Simplifying regimen characteristics,

Imparting knowledge,

Modifying patient beliefs,

Patient communication,

Leaving the bias and

Evaluating adherence.[3,4]

What are the factors affecting the Medication non-compliance?

The non-compliance varies in the disease course in many conditions the symptoms of the disease motivates the patients to be adherent to treatment. However induce course the symptoms are first disappears giving an impression to the patients that he is free from disease and thinks the medicines are not needed. Unfortunately the patient unilaterally takes a decision to stop medication. The other factors like high cost of medicines, distinct bother some side effects of medications, the complexity of the treatment poor inadequate and communication, difficulty in access of healthcare delivery centre for follow-up and lack of belief in benefit of treatment.[5]

What are the consequences of poor Medication Compliance?

The medication planning is a personalized and customized protocol for a patient. The planning is based on diagnosis and sound decisions to revert back the patients to normalcy from the disease and disorder. The outpatient and ambulatory patients in whom the poor medication compliance is more common than in-patients end up with poor outcomes and wastage of economic resources. The patients who are not following the instructions of the care giver have the risk of getting into sever suffering and death. For example poor compliance of treatment of diabetes may lead to diabetic foot which may end-up with amputation of the limbs. The other dimensions of importance includes increased burden of hospitalizations and emergency visits to hospitals.

What is the role of Pharmacist in addressing the challenges of poor Medication Compliance?

The patients have to meet and interact with pharmacists for medication supply. They usually visit hospital, community, and central and 24hrs pharmacy to collect the prescription medicines. The pharmacists are bestowed with the responsibility of ensuring the quality use of medicines for the prescriptions dispensed. They have to quickly interact with the patients or attendant of the patients and assess the need of pharmaceutical care and make a plan and implement it. He should stress upon the precautions and the instructions of safe use of medicines. He should clearly instruct the need for completing and adhering the instructions given by doctors for achieving the best outcomes of therapy.

What is the difference between medication adherence and Medication Compliance?

The subtle difference between the terms "adherence" and "compliance" is on how patient is referred and treated. The non-compliance represents the laps by the patients to follow the instructions given by care giver. Whereas non-adherence represents the causes for not cooperating with the therapy which includes other causes beyond patient's role. On these interpretation when extended to "adherence" and "compliance". The adherence accounts for patients and beyond patients causes helping the agreement to the treatment. Regardless of which term one uses, adherence involves several complexly related factors, including difficult medical regimens, medication toxicity, and perception of the regimen's value.[6] Understanding these forces can facilitate clinical recognition of non-adherence and implementation of strategies to improve adherence.

What is the impact of poor medication compliance on clinical outcomes?

The poor medication compliance disturbs and distorts the therapeutic plan as a result of it the outcome becomes unpredictable due to irrational use of medicines. There can be inappropriate dosing change in the timing of the medicines leading to disturbed pharmacokinetic profile resulting in unpredictable outcome which may not address the therapeutic issue of concern.

What is the impact of poor medication compliance on economic outcomes?

The poor therapeutic outcome means the patient continuous to suffer and remain ill where in states of the patient can be described as unaffected and unchanged. Whatever the inputs in terms of drugs and services need to be readministered as the expected outcome has eluded and the resources went as a waste. The patient has also increased risk and may have to spend more money to regain the health. Hence the poor medication compliance can escalate the treatment cost and cost of direct and indirect expenditures of the patients.

What is the impact of poor medication compliance on health related quality of life?

The health related quality of life (HRQoL) is a qualitative measure which ascertains the value of treatment expressed by patients them self. The quality of life is a reflection of clinical outcomes. The poor medication compliance results in poor clinical outcomes. This affects the HRQoL in a negative manner.

What is the role of patient education in addressing the issues of poor Compliance?

The poor compliance is a result of ignorance on the matter of drug, disease and lifestyle modifications influencing the clinical, economic and quality of life outcomes. If patient is aware and sensitized regarding the poor outcomes and explained how this can be improved by following instructions of healthcare provider by patient education. The patient would develop an attitude and resort to practice good compliance.

How the quality use of medicines is related to patient's Compliance?

The quality use of medicines refers to optimized rational use of medicines which begins from affordability and accessibility till the good outcomes in terms of clinical and QoL are achieved. So quality use of medicines takes care of minimizing adverse drug reaction events and maximizes the patient comforts and benefits. For example the application of Directly Observed Treatment, Short Course (DOTS) is based on quality use of medicines in cure of Tuberculosis is demonstrated as successful.

What happens, if patient himself decides to stop medication as he finds no change in taking medicines?

This is a frequently observed phenomenon in treatment of hypertension and diabetes. Unlike diseases like Rheumatoid Arthritis (RA) the patient's decision to stop medication can aggravate the disease condition usually causing serious complications resulting in hospitalizations. The risk is very high as in terms of mortality and morbidity for the patients who without knowing how the drug is preventing the problems of disease may have to spend unnecesaiary hospital and medical expenditures.

How to identify a patient who is having trouble in medication compliance?

The best way to identify a patient by direct interaction by health care providers like pharmacists. The pharmacists can make treatment regarding the basic knowledge of the patients in the area of drug, disease and life style factors. The approach involves pill count and clinical outcomes check.

What is the impact of poor patient compliance in chronic disease management?

The chronic diseases effects the patients health in a slow, silent and sudden manner for example the essential hypertension which was not monitored and controlled over several months slowly alters the patients health by damaging vital organs like kidneys and blood vessels. There will be no symptoms and patients may not get alerted regarding the damage happening which is usually ignored. The uncontrolled prolonged hypertension ends with serious causalities like stroke, heart failure and kidney damage.

What are the technology advances to address the challenge of medication compliance?

The mobile health (m-health) uses the Short Message Service (SMS) as tool to alert and remained the patients regarding dosing schedule. The use of multimedia based e-Health, Tele-Health You-Tube, pictograms are easy and effective in patient education.[7] The smart phone Apps are easy to use for patient education, monitoring of disease conditions. The Pill dose or dose set boxes with electronic light emitting facilities can helps patients in remembering whether the medicine is missed out due to forgetfulness.


1. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487-97.

2. Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive Validity of a Medication Adherence Measure in an Outpatient Setting. The Journal of Clinical Hypertension 2008; 10(5): 348-354.

3. Atreja A, Bellam N, Levy SR. Strategies to enhance patient adherence: making it simple. MedGenMed. 2005;7(1):4.

4. Uday Venkat M, Rajesh V, Srikala P, Anantha Naik Nagappa. A Systematic Review on the Tools and Indicators of Medication Adherence. The Pharma Review. 2011; September - October 2011;137-139.

5. Improving Medication Adherence in Older Adults: What Can We Do?. Available from: [Last accessed on Aug 01,2014].

6. Miller LG, Hays RD. Adherence to combination antiretroviral therapy: synthesis of the literature and clinical implications. AIDS Read. 2000;10(3):177-85.

7. Dayer L, Heldenbrand S, Anderson P, Gubbins PO, Martin BC. Smartphone medication adherence apps: potential benefits to patients and providers: response to Aungst. J Am Pharm Assoc (2003). 2013; 53(4):345.

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About the Author

Anantha Naik Nagappa's picture

I am professor, intrested in developing the community pharmacy services in India, We have an association called ASSOCIATION OF COMMUNITY PHARMACISITS OF iNDIA. CHECK AT for further detials


Albert Ana-Maria's picture

Very good !

Hitesh Patel's picture

If I am a retail pharmacist in India , what procudere you suggest to coach my coustomers to make them compliance .  Could you please advise step by step procedure that i can follow especially keeping India in mind ?

Anantha Naik Nagappa's picture

In India adequate regulations, guidelines and infrastructure available but unfortunately the lacksidal approach of the stakeholders due to personal gains and innocent consumers has given birth to serious situations where in prescription drugs are sold openly to public in demand. Moreover the model of business dose not encourage or pay any reward for the pharmacist showing interest in patient counseling and other activities like patient safety etc. A retail pharmacist earns his profits on margins of sale volumes rather than helping the patients. So this background I have no ground to say any answer for you are question

Prof Anantha Naik Nagappa

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