This document, issued in collaboration with ESTEVE, is part of the 'ADHe+' project and intends to strengthen the role of pharmacists in the scope of adherence and help them detect noncompliant patients during dispensation in community pharmacies.

On account of their proximity and their knowledge of patients and drugs, the role of pharmacists is indispensable.

Adherence to and effectiveness of treatment are closely related; today, 1 of 2 chronic patients fails to comply with their treatment.

On the occasion of the International Day for Adherence, the Spanish Society of Family and Community Pharmacy (SEFAC), in collaboration with ESTEVE, has issued the document Dispensation, adherence and proper use of treatment. This is a practical guide created in the framework of the ADHe+ project, and intends to strengthen the key role of community pharmacists in the scope of adherence and help them detect noncompliant patients during dispensation. Indeed, up to half the patients with chronic diseases currently fail to properly adhere to the prescribed treatment.

The degree of adherence to and effectiveness of treatment are closely related. Besides the impact on health outcomes, the lack of adherence also imposes costs upon the health system -125 billion euros and 200,000 premature deaths a year, as well as poorer quality and shorter life expectancy. Also, a rise in the ageing population (Spain is currently the second country in the OECD with the highest life expectancy), in chronic diseases and in polymedicated patients are factors that add to this healthcare problem.

All this makes the lack of therapeutic adherence a major healthcare problem. The data speaks for itself: the lack of adherence is 50% in chronic patients and up to 75% in psychiatric patients, 70% in asthmatic patients, and 50% in patients with high blood pressure, diabetes or cholesterol.

Adherence must be approached in a multidisciplinary fashion, with a joint strategy and the participation of all the actors involved (patient, family, caregiver, and professionals) to detect the lack of adherence and implement effective actions. This concerns particularly the first link of healthcare providers, such as community pharmacists. On account of their strategic position and knowledge of patients and medicines, community pharmacists are a key and indispensable pillar to strengthen the prescription of the physician and follow up compliance by the patient.

The purpose of Dispensation, adherence and proper use of treatment is to provide pharmacists with useful, integrable tools in daily practice to help them detect patients who fail to comply with treatment as prescribed, build a relationship of trust to ascertain the reasons why the patient is not fully compliant, and be able to redirect this lack of adherence.

Rosa Prats, a community pharmacist who coordinated the work of the experts who wrote this document, notes that "community pharmacists are a key factor in the approach to adherence. Indeed, they are the last link of the chain before the patient receives the medicine. This guide is therefore a great tool that easily and rapidly helps the pharmacist detect and approach non-adhering patients during dispensation, regardless of whether they decide to collect the medication or not".

In this sense, the final decision on the strategy should be individualized bearing in mind the circumstances that surround each patient and their condition, and using simple measures adapted to these circumstances: behavioral or educational techniques, social and family techniques, or techniques directed to the healthcare provider, the Administration, the industry or a combination thereof. Also, involving the patient as an active part of this strategy is essential, this being part of their empowerment in health.

Many factors influence adherence

Adherence is a concept that goes beyond simply taking the medication. It includes the patient's involvement and commitment to their disease, their treatment and the healthcare providers around them, and is a complex problem that involves many different factors.

Some of the key factors involve the patients themselves, such as age -the elderly tend to forget their treatment and the young tend to question it-, the presence of psychological problems such as depression -the adherence of these patients is only 28% in Spain-, or the degree of unawareness of the disease, the treatment and the consequences involved with noncompliance.

Other factors are related to therapy, such as complex therapies -there is an inverse relationship between the number of prescribed doses and adherence-, the presence of adverse effects, the perception that treatment is not effective enough, the acceptation and flexibility of therapy, and the duration of treatment, the existence of previous failures and the frequent changes in medication.

The status of the disease also plays an important role. Patients diagnosed with a single condition show a significantly higher adherence rate (54%) than those with two or more diseases. In addition, the presence of symptoms is a stimulus because symptoms act as a reminder and strengthen the perception of need. For example, patients with asymptomatic chronic diseases such as diabetes and high blood pressure adhere less because there is no awareness of the disease, while acute diseases with painful symptoms increase adherence.

Also to be considered are the factors related to the personnel and the health system: the lack of time for doctor-patient communication is a reason for dropout from treatment and, in chronic diseases, the patient should be monitored periodically to ensure the success of treatment. Finally, the patient's social and family situation also has an impact. Social and emotional support, a cohesive family environment and not living alone increase adherence rates. On the other hand, the higher prices of medicines and co-payment of government-funded drugs increase the patient's expenditure in medicines and may become a barrier to adherence.

The ten key points for communicating with the patient
Identifying the barriers to treatment adherence is the first step to determine which interventions are most appropriate to improve it. To do so, a good communication between the patient and the community pharmacist -empathy, well-thought-out questions and careful listening- is essential.

Patients need to feel comfortable when they are asked about their doubts and worries about the medication. And the pharmacist needs to understand the reasons why the patient is not taking the medication properly.

The document Dispensation, adherence and proper use of treatment provides another nine key points for pharmacist-patient communication:

1. Establishing in each case the most appropriate means of communication by considering the use of drawings, symbols and even different languages.

2. Encouraging patients to ask questions about their disease and their treatment.

3. Using open questions.

4. Talking about the repercussions of not taking the medication, about other non-pharmacological alternatives, about how to gradually reduce doses, and about which medicines should be prioritized (in case of polymedicated patients).

5. Giving the patient the opportunity to become involved in the decisions about their treatment.

6. Evaluating adherence with the patient, without criticism.

7. Accepting that the patient may have a different point of view.

8. Knowing that there is not one specific recommendation valid for all patients.

9. Periodically reviewing with the patient their knowledge, understanding and worries about their medicines -these vary over time.

The five different patient profiles

In Dispensation, adherence and proper use of treatment two types of adhering patients and three types of non-adhering patients are defined. The action of the pharmacist to improve adherence will depend on each profile.

Adhering patients may be classic or exemplary. Classic patients are generally males older than 65 years with good life habits and good levels of adherence, although they actually do not understand why they comply with their treatment. Exemplary patients live in large households, have good health habits and their collaborative and active attitude, together with their persistence and strictness, determines their high levels of adherence. No specific actions are required with these patients.

Non-adhering patients are classified as confounded, mistrustful and trivializers. Confounded patients are older than 65 years, and most are multi-pathological, polymedicated and chronic patients who often live alone and are unable to comply with treatment on account of its complexity (number of drugs and way to take them).

Mistrustful patients are younger than 45 years, their lack of trust in the healthcare provider prevails over their capacity for self-management, and are usually demanding of their doctor and their treatment. While they are aware of the importance to comply with treatment, the lack of a good relationship with the professional is a conditioning factor. Finally, trivializers are younger than 45 years, have medium-high education and only one disease, receive only one treatment and have family support. The main barrier to adherence is their lack of involvement in their disease and their little persistence.