August 23, 2002
"People's adherence was really low at the beginning with 55 percent to 57 percent, and the pager system did improve adherence," said Steven Safren, Ph.D., coauthor and research scientist at Fenway Community Health in Boston. Safren is also an associate director of the Cognitive Behavioral Therapy Program at the psychiatry department of Massachusetts General Hospital and an assistant professor at Harvard Medical School.
After two weeks of being prompted by the pager system, adherence climbed to 70 percent, but it fell back to 64 percent after 12 weeks, he said. The group of HIV patients who did not receive the pager prompts had adherence rates of 56 percent at two weeks and 52 percent at 12 weeks. The pager delivered timed instructions like, "Remember, don't eat for the next hour," or "Take your pill, and don't eat for the next two hours." Adherence was assessed through a pill bottle system that recorded each time it was opened.
Since the paging system has not proven to be highly effective, clinics and physicians seeking to improve patient adherence should consider an approach that uses more than one strategy. For example, a paging or reminder system could be combined with counseling and behavior modification. In the case of a patient with severe social and behavioral problems, a program could have them return to weekly one-on-one meetings to work on their adherence skills, and they could be given both a pill box and a reminder system, such as a pager or watch alarm, Safren said.
Another strategy is for a counselor to have the patient go through a checklist of steps that help the patient plan for taking the medication. These steps may include memory cues, such as having the patient schedule to take pills during another daily task. The morning pills could be taken when the patient brushed his or her teeth, for instance, Safren said. "A lot of HIV-related interventions involve three components: information, motivation, and behavioral skills," he said.
The information component would include educational materials, as well as individualized education. Motivational interviewing, a technique sometimes used for people beginning or considering a behavioral change, may include an exercise in which an interviewer asks a patient to examine the short-term and long-term pros and cons of a behavior. The focus on behavioral skills may include providing patients with assistance in achieving adherence, such as teaching them skills to cope with medication side effects, Safren said, or teaching patients to think about why they are taking their medications each time they feel that the medication makes them feel worse or is too much trouble.