Including a behavioural component into educational interventions may enhance medication adherence in children and adolescents with chronic illness
- Correspondence to Allison Williams
The University of Melbourne, Level 5, 234 Queensberry Street, Carlton, Victoria 3053, Australia;
Adherence to long-term medications for chronic conditions in developed countries averages 50%.1 Medications do not work unless they are taken as prescribed. Few studies have examined adherence-enhancing interventions in children and adolescents with a chronic condition.2 This is an important area of research as optimal adherence patterns need to be established early in the long-term management of chronic conditions for best possible outcomes.
Dean and colleagues searched data from MEDLINE, PsycINFO, CINAHL, International Pharmaceutical Abstracts, the Cochrane Library and Web of Science from January 1980 to June 2007 using the terms (adherence.ti OR compliance.ti OR concordance.ti) AND (child$ OR adolesce$ OR pediatr$) AND (intervention OR treatment OR trial OR medication) to locate clinical trials that tested adherence interventions implemented by a variety of health professionals. Inclusion criteria stipulated that the intervention targeted participants aged ≤18 years, a prescribed medication for ≥1 month and medication adherence as an outcome measure. Of 122 possible articles, 17 studies were chosen to best meet these criteria.
Seven studies examined education interventions, two of which showed an improvement in urine drug assays and prescription refills. Seven studies examined behavioural interventions with or without education: two studies incorporating education using blood drug assays and electronic pill monitoring and three studies incorporating education using self-report showed the intervention group to be more adherent to one prescribed medication. Another three studies used education combined with a psychological intervention, two of which resulted in poorer adherence. Interventions which combined behavioural and educational approaches and were more than ‘one-off’' sessions were more likely to enhance medication adherence, whereas there is no clear benefit on education alone, or in combination with psychological interventions.
The authors have managed to make sense of this very complex area of investigation examining adherence in children ≥1 year of age through to late adolescence. As with reviews of adherence-enhancing interventions in adults with chronic conditions, analysis was plagued by methodological challenges. Estimating the worth of each study was made more difficult with the use of different measures and estimates of adherence, non-powered samples without description of usual care, inadequate description and assessment of the various components within interventions or the clinical outcomes of improved medication adherence. Three studies included participants ≤19 years of age in the extraction process highlighting difficulties in selecting studies for inclusion. Few studies had long-term follow-up to demonstrate sustained behavioural change. The development of children from dependency to increasing autonomy over time with varied levels of parental input makes longitudinal studies more challenging.
The findings of this systematic review are similar to the work of Roter and colleagues3 and Schroeder and colleagues4 who studied medication adherence-enhancing interventions in adults. These authors recommended combinations of tailored educational, behavioural and affective strategies that included family support and regular patient contact. Dean and colleagues highlight the importance of adherence-interventional research measuring adherence at the outset – using objective measures of adherence, the inclusion of clinical outcomes of medication adherence and the need for long-term interventional work in routine clinical practice.
Implications for practice
The role of the parent in medication adherence is critical to ensure the child receives the therapeutic benefit of the prescribed medicine. Children's behaviour will change over time as the child develops where interventions need to be adapted to these changes within the family. Tailored interventions need to be delivered in a non-judgemental way and integrated into the routine care and follow-up of patient care at each point of contact across a range of healthcare settings by a multidisciplinary team. Health professionals need training in communication to routinely monitor and promote medication adherence across the life span. Haynes and colleagues1 stated that more frequent interaction with patients with attention to adherence may be the most important strategy which is likely to pay large dividends in chronic illness management.
An examination of specific groups of individuals requiring medication-enhancing interventions, such as parents and carers of dependent care recipients or children and adolescents who self-administer medication without supervision, is warranted. The consumers' perspective (children and adults) needs to be incorporated into the development and evaluation of medication-enhancing interventions. Many children and adolescents are required to take more than one prescribed medicine and research investigating adherence to multiple medicines in this group, and the influence of the type of chronic condition on adherence deserves investigation.