title: Understanding if, how and why non-adherent decisions are made in an Australian community sample: a key to sustaining medication adherence in chronic disease?
abstract: BACKGROUND
  Adherence to medications for chronic disease is sub-optimal. Current adherence-enhancing strategies do not seem to adequately address the fundamental need to sustain adherence or prevent non-adherence. Intentional non-adherence, involving active medication-taking decisions, is not well described within the Australian community setting. Understanding if, how and why non-adherent decisions are made may help develop strategies to sustain adherence in chronic disease.
  
  
  OBJECTIVE
  This study aimed to describe intentional non-adherent behavior in chronic disease within the Australian community setting and identify the factors that promote and prevent non-adherent decisions.
  
  
  METHODS
  In-depth, semi-structured interviews were conducted with 21 patients (12 rural, 9 metropolitan; New South Wales) prescribed medications for a diverse range of chronic conditions. Using the Theory of Planned Behavior as the theoretical framework, an iterative thematic framework analysis method was used to characterize the intentions and the decisions underlying non-adherent behavior. Data were indexed and charted within the thematic framework using Excel, and linked themes were combined, and associations and explanations drawn.
  
  
  RESULTS
  Although there was a strong intent to follow prescribers' recommendations, most patients described instances of intentionally non-adherent behavior. Trading between perceived treatment inefficacy, unfavorable side effects and unaffordable medication costs promoted non-adherent decisions; trusting prescriber-patient relationships, positive family values and lack of perceived control over treatment choice maintained adherent intentions. Intentional non-adherence was mostly temporary.
  
  
  CONCLUSIONS
  Intentional medication non-adherence in chronic disease appears reversible and amenable to interventions that address treatment-related barriers such as medication affordability. Strategies that strengthen patient-prescriber relationships and empower patients as informed decision-makers may help maintain adherence intentions. Crucially, regular and sustained interventions that are refreshed to meet the changing needs of patients are needed to curb the temporal decline in adherence to chronic disease medications.
authors.affiliation: The University of Sydney, Faculty of Pharmacy, Camperdown, Sydney, Australia; The George Institute for Global Health, Camperdown, Sydney, Australia. Electronic address: tlaba@georgeinstitute.org.au.
authors.forename: Tracey-Lea
authors.initials: TL
authors.lastname: Laba
authors.affiliation: Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, UNSW Medicine, The University of NSW, Sydney, Australia.
authors.forename: Elin
authors.initials: E
authors.lastname: Lehnbom
authors.affiliation: The University of Sydney, Faculty of Pharmacy, Camperdown, Sydney, Australia; The University of New South Wales, UNSW Medicine, Kensington, Sydney, Australia; St Vincent's Hospital, Darlinghurst, Sydney, Australia.
authors.forename: Jo-Anne
authors.initials: JA
authors.lastname: Brien
authors.affiliation: The George Institute for Global Health, Camperdown, Sydney, Australia; The University of Sydney, School of Medicine, Camperdown, Australia.
authors.forename: Stephen
authors.initials: S
authors.lastname: Jan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002908:Chronic Disease; D003657:Decision Making; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D055118:Medication Adherence / Q000523:psychology; D008875:Middle Aged; D009517:New South Wales; D012424:Rural Population / Q000706:statistics & numerical data*; D014505:Urban Population / Q000706:statistics & numerical data*; D055815:Young Adult; D016903:Drug Monitoring
keywords: Chronic disease; Decision-making; Medication non-adherence