for Nonadherence

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© Springer Nature Switzerland AG 2020
S. R. Feldman et al. (eds.)Treatment Adherence in DermatologyUpdates in Clinical

1. Reasons for Nonadherence

Adrian Pona1  , Abigail Cline1 and Steven R. Feldman2

Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC, USA

Departments of Dermatology, Pathology and Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, USA



Adrian Pona


NonadherenceHealthcare providerPatientReasonsBarriers


Poor patient adherence is especially challenging in the field of dermatology, where only 50% of patients with chronic skin conditions adhere to the treatment plan outlined by their provider [1]. About one-third of patients never redeem their prescriptions from a dermatology clinic. Even if patients do fill the prescriptions, adherence often drops off after a few days. Poor adherence leads to poor health outcomes and increased financial expenditure for patients. By recognizing and addressing common barriers to treatment adherence, providers may help patients successfully incorporate and adhere to treatment regimens. Improving patient adherence may provide a convenient way to improve patient outcomes and decrease healthcare costs.

While there are various reasons for nonadherence, one conceptual model of barriers to adherence focus on patient, prescriber, and healthcare system factors [2]. Nonadherence can also be categorized into three phases: initiation, implementation, and persistence. Initiation includes failure to fill and begin taking a prescription [3]. Implementation is the patient’s ability to agree, comprehend, and translate the healthcare provider’s instructions. Finally, persistence involves maintaining the recommended treatment regimen [3, 4].

This chapter will first discuss barriers specific to patients, providers, and healthcare systems, then it will discuss common barriers that are shared between patients and providers.

Patient-Centered Barriers

Patient barriers create a significant practice gap in all specialties. A patient-centered approach may help providers investigate potential risks for nonadherence. To bridge practice gaps, patient barriers must be recognized. Patients may fail to take their medication unintentionally or intentionally. Unintentional nonadherence may be related to forgetfulness, complex treatment regimens, and psychiatric illnesses [58]. Reasons for intentional nonadherence may include patient beliefs, fear of adverse effects, and patient preference (Table 1.1) [9].

Table 1.1

Intentional and Unintentional Reasons for Nonadherence [114]



Patient beliefs


Fear of adverse effects

Lack of health-related education

Patient preference

Psychiatric illnesses

Complex treatment regimen

Poor communication

Medication cost

Failure to refill medication

Insurance difficulties

Limited access to healthcare

Poor patient-physician relationship

Poor patient-physician relationship

A patient’s beliefs can influence whether they initiate, implement, and persist with therapy. A patient may believe he received the wrong diagnosis, and therefore wrong medication, from his provider. If a patient feels he was not adequately examined and understood, he may be less likely to fill or take the suggested medication. A patient might also believe his condition is only temporary, and therefore prematurely stop therapy after some improvement. This can be especially challenging in chronic conditions that require continuous treatments [10].

A common reason for intentional nonadherence is a patient’s fear of adverse effects due to the medication [11]. “Steroid phobia” describes negative feelings and beliefs about using topical corticosteroids. Common concerns about topical corticosteroids include skin thinning, the potential of topical corticosteroids to affect growth and development, and nonspecific long-term effects [12]. In one study, prevalence of steroid phobia in caregivers of children with atopic dermatitis (AD) reached about 38% [12]. If patients or caregivers fear of the topical corticosteroid side effect profile, they may be less willingness to use the medication as prescribed.

Patient preferences can impact adherence; therefore, a patient-centered approach may be helpful. Addressing and reconciling patient goals and preferences can help providers and patients agree on a feasible treatment regimen [13]. For example, some patients with severe psoriasis may prefer oral over injectable medications, even if the injectable medication is more likely to result in better disease control. Patient preference of a particular vehicle formulation for their topical medication may also impact their level of adherence [14, 15]. Subjects satisfied with their prescribed medication are more adherent than unsatisfied subjects (P < 0.001) [16].

Prescriber-Centered Barriers

Although the responsibility for poor adherence is often placed on patients, there is much that physicians and the healthcare system can do to enhance adherence behavior (Table 1.2). Providers may contribute to patients’ poor adherence by prescribing expensive medications that patients cannot afford, recommending complex regimens that are difficult to follow, and failing to adequately educate patients on the medication’s benefits and side effects. All of these factors lead to a poor patient-provider relationship, which can also result in poor adherence [11]. By recognizing and addressing provider-specific barriers, providers can standardize how they prescribe and improve adherence outcomes in patients.

Table 1.2

Patient , prescriber , and Healthcare-Centered Barriers to adherence [19, 1118]

Patient-centered barrier

Prescriber-centered barrier

Healthcare-centered barrier


Complex treatment regimen

Limited access to healthcare

Psychiatric illness

Prescribing high cost medications

Restricted formularies

Patient beliefs

Poor communication

Medication cost

Fear of adverse effects


Switching formularies

Patient preference



The high cost of prescription drugs means many patients cannot afford their medications. Patient may fail to pick up their medications, skip doses to make the medication last longer, or stop treatment early due to the cost. However, providers are often unaware how much medications will cost patients. Providers and patients often fail to seek out pricing information before filling prescriptions. Prescribing generic prescriptions increases the likelihood that the patient can afford a medication [17].

Complex treatment regimens often confuse patients and decrease their motivation, leading to poor adherence. Prescribing multiple medications after one office visit or adding prescriptions on top of a large list of medications, can reduce patient adherence. Simplifying treatment regimens reduces the burden of treatment and increases the likelihood that patients will adhere. Patients are more likely to follow a once daily treatment compared to twice daily. Combination medications also reduces the burden of treatment and increases adherence [11, 18, 19].

Poor communication by the provider to the patient can also result in poor adherence. Providers may not adequately explain the patient’s condition, the need for medication, treatment expectations, and potential adverse effects. Patient education is be a key component of the clinical encounter. It offers an opportunity to address patient concerns and build a strong patient-provider relationship. By failing to communicate basic information, healthcare providers may jeopardize a patient’s disease and treatment understanding and overall adherence [11, 20, 21].

Prescribers who fail to create a strong bond with their patient may increase the risk of nonadherence. Using a patient-centered approach may strengthen trust between both parties and prevent a poor patient-provider relationship [11, 2224].

Healthcare-Centered Barriers

Healthcare-associated barriers to adherence include limited access to healthcare, restricted formularies, switching to a different formulary, and high costs for medications, copayments, or both [2527]. The patient, provider, pharmacies, hospitals, insurance, and pharmaceutical companies are all components of the healthcare system [28].

Factor that create poor access to healthcare— including living in an area with poor access, lack of transportation, lack of adequate insurance, financial issues, and absence of other resources— also influence adherence [17, 29]. Other healthcare-associated factors that may influence adherence include extensive waitlist for an appointment with a specialist, lengthy wait time within the clinic, and confusing healthcare referral systems [3032].

Insurance also has a strong influence on healthcare-associated nonadherence. Insurance issues include difficulty finding in-network healthcare providers, drug plans that do not cover certain prescription medications, and unaffordable copayment [11, 22, 23, 33]. For example, providers may not prescribe the best medication if it does not fall in a patient’s restricted network formulary [34]. Such limitations impact the patient, provider, and healthcare system.

Common Barriers of Patients and Providers

Most adherence barriers are described as patient-oriented, but reframing common barriers as provider-oriented can help physicians influence adherence [11]. The focus of this section is to identify and discuss barriers to medication adherence that are common to both patients and providers (Table 1.3). Examining shared barriers from both patients and providers highlights each of their specific responsibilities to address these concerns.

Table 1.3

Common barriers for patients and providers [6]



Treatment education

Poor health literacy

Poor communication skills

Beliefs and perception of symptoms

Fear of adverse effects

Believing patients are adherent

Treatment dissatisfaction

Failure to acknowledge patient beliefs


Failure to remember regimen

Failure to provide instructions

Psychiatric illness


Failure to recognize psychiatric comorbidities


Failure to provide appropriate referrals

Cost and insurance

Lack of insurance

Writing expensive prescriptions

Expensive copay

Failure to provide patient assistance

Complex treatment regimen


Prescribing multiple medications

Inability to follow instructions

Failure to offer prompt return visit

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Mar 23, 2021 | Posted by in Dermatology | Comments Off on for Nonadherence
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