How to Make Patients Want to Do Medication They Have to Do

Anna Jo(blessedanna.j@gmail.com)

Jiyoung Ryu(jyryu1@gmail.com)

Summary

As solvers of this challenge, we identify that the seeker for this challenge is

interested in several approaches, case studies, previous literatures describing the factors how

people, especially patients, are committed in their routines. The aim of this challenge is to

summarize the current knowledge in the field of overcoming the poor adherence problem in

order to make people “want” to do things they “have” to do. Our approaches begin with how

to overcome poor adherence according to targeted people. Secondly, we apply a typology of

consumer loyalty program to treatment or medication program. Based on the information, we

additionally investigate prior studies which describe several cases of medication adherence

and the medication program. Then, we discuss potential factors for facilitating the higher

level of adherence by employing self-determined motivation and factors affecting medication

adherence. We introduce five sets of factors: social/economic factors, provider-patient/

healthcare system factors, condition-related factors, therapy-related factors/ patient-related

factors. Finally, we discuss strategies to overcome each barrier based on potential factors and

conclude how to achieve in order to achieve higher level of medication adherence.

Table of contents

Summary

The Main Issue I. A Detailed Description of an Approach, Program, Case Study

1. Several Approaches according to targeted people

2. Loyalty Program Implemented by Consumer-Oriented Companies

3. Case Study: Treatment or Medication Adherence

II. A Discussion of Potential Factors for Facilitating the Higher Level of

Adherence

1. Self-determined motivation

2. Factors affecting medication adherence

III. A Discussion of How the Input from This Particular Case Could be

Implemented for Achieving Higher Level of Sticking to Medication

1. Methods of measuring adherence

2. Achieving higher level of medication adherence

Conclusion

Reference

The Main Issue

I. A Detailed Description of an Approach, Program, Case Study

1. Several approaches according to targeted people

(1) Who don’t consider their personal health a priority

a. One of the factors is lack of understanding the gravity of their illness or the benefit that the

medication will provide.

=>Warning for the amount of damages and physical loss in the case of a unexpected relapse

of the condition of a disease

b. Education concerning the phase and symptom of disease when patients passed their

therapy (Table 2. Case study 1, 2, 3)

c. Offering interview with a terminal patients

(2) Who are not sure they even want to deal with their condition

a. Motivating patients by presenting and sharing success stories of other similar patients

(Table 2. Case study 4)

b. Providing statistical information or experimental results describing the gravity of their

illness.

=> Research says that lack of understanding about seriousness of the disease would result in

lack of motivation.

(Steven Baroletti, PharmD, MBA, etc. Medication Adherence in Cardiovascular Disease,

Circulation. 2010; 121: 1455-1458)

(3) Who are not always convinced in the value of medication

a. Informing patients about medication benefit will help patients to convince about their

medication value.

=> In this case, communication plays critical roles for success of convincing patients.

Doctors may adopt following communication skills for discussing evidence with patients

such as using non-technical language or drawing diagrams with comfortable environments.

(Table 2. Case study 1, 2, 3)

(Reference: Ronald M. Epstein, MD, etc. , Communicating Evidence for Participatory

Decision Making, JAMA. 2004;291(19):2359-2366. doi: 10.1001/jama.291.19.2359)

b. Giving an opportunity to take part in clinical demonstration such as animal tests

(4) Who have lower levels of confidence in themselves and their doctors

a. Encouraging patients by keeping in touch with them and their family using SNS services

b. Providing governmental periodical verification and rating service in homepage of National

Healthcare Service regarding hospitals and doctors before patients see a doctor

=> An in-depth interview studies show that patient-doctor relationship, Outside influence,

Professional expertise are three major areas that should be considered for patients’ beliefs and

preferences regarding how doctors decide to recommend a medication. Following factors

may affect the trust of patients toward medication recommended by doctors and fulfilling

these factors will guard or enhance patient-doctor relationship.

n Patient-doctor relationship: Trust, Familiarity with patient, Shared decision

Making(Addressing equipoise -no clear scientific evidence for 1 treatment choice

over another), Communication honesty

n Outside influence: Distrust toward pharmaceutical detailing(Doctor receiving gifts

from detailers), Cost(Drug equivalency, HMO Regulations, Transparency)

n Professional expertise: Medication knowledge (Effectiveness, Side effects),

Knowledge that the doctor is stayed familiar with current medication information

through lifelong learning strategies such as journal reading and conferring with

colleagues.

2. Loyalty Program implemented by consumer-oriented companies

l Types of consumer loyalty programs and application of treatments or medication

adherence based on the loyalty programs

There are four broad categories of loyalty programs which are ways for retailers to

encourage repeat purchasing of customers (Berman 2006). In Table 1, type I program is an

elementary connector for customer relationship, in that occasional customers receive same

discount deals as a firm’s best customers. According to Berman(2006), however, type I

program familiar with supermarket program do not guarantee sustainable customer loyal

behavior. In a type II program, consumers get quantity discount based on their total purchase

and easily self-manage their purchase. The reward getting a free good such as a free hair cut

is motivating another purchasing. Type III programs are membership programs which offer

reward points based on the past purchase records of consumers. Major providers of type III

programs are airlines, hotels, credit card companies. Because the type III programs facilitate a

member's accumulating points and increase the variety of reward options, they effectively

promote consumer loyalty. In type IV programs, individual members receive specialized

promotions and rewards based on their purchase history beyond discounts. Therefore, the

type IV programs lead consumer commitment to a firm and enable to provide the most

relevant deals.

Program Type

Characteristics of

Loyalty Program

Application of

Treatment or medication

adherence based on the

loyalty programs

Type I: Members receive

additional discount at

register

-Membership open to all

customers

-Each member receives the

same discount regardless of

purchase history

-There is no targeted

communications directed at

members

-Periodicals which issue

Treatment discount coupon

Type II: Members receive 1

free when they purchase n

units

-Membership open to all

customers

-Firm does not maintain a

customer database linking

purchases to specific

customers

-When patients begin their

medication, hospitals or

clinics induce them to pay

for the entire cost of their

medication including 1 free

medication.

-Type III: Members receive

rebates or points based on

cumulative purchases

-Seeks to get members to

spend enough to receive

qualifying discount

-Treatments or medications

in one hospital or clinics

include reward programs so

that patients can accumulate

points which are available on

their health check-up

Type IV: Members receive

targeted offers and

mailings

-Members are divided into

segments based on their

purchase history

-Requires a comprehensive

customer database of

customer demographics and

purchase history

-Patients receive specialized

healthcare information based

on their past diagnosis and

diseases.

Table 1. A Typology of Loyalty Program (resorting to the table in Berman(2006))

As with customer relationship marketing, healthcare service providers needs to

consider how to attract people maintain high level of treatment adherence once they start it.

In table 1, we summarized plans to promote treatment or medication adherence for patients

based on each type of consumer loyalty program. Even though consumer loyalty programs

suggest successful adherence schemes, treatments or medication require clsoser individual

care such as disease management.

3. Case Study: Treatment or medication adherence

Representative cases for treatment or medication adherence have been individualized

communication and intervention by telephone or in-person. As described in consumer loyalty

programs, a few cases employ financial incentive programs to enhance efficiency of disease

management.

Case1 Title JAMA, October 13, 2004—Vol 292, No. 14

Influence of Patient Literacy on the Effectiveness of a Primary

Care–Based Diabetes Disease Management Program

Methodology 1) Individualized communication, one-to-one educational

sessions including counseling and medication

management, helps manage glucose and cardiovascular

risks by allowing pharmacists to both initiate and titrate

blood pressure and glucose lowering medications,

including telephone reminders and, when needed,

addressing difficulties with transportation,

communication, and insurance.

2) Intervention by telephone or in person every 2 to 4 weeks

(more frequently if indicated). Communication to patients

was individualized using techniques that enhance

comprehension among patients with low literacy,

including predominantly verbal education with concrete,

simplified explanations of critical behaviors and goals;

“teach-back” to assess patient comprehension; and

picture-based materials. Main topics, revisited throughout

the follow-up period, included treatment goals,

identification of hypoglycemic and hyperglycemic

symptoms, prevention of long-term complications, and

self-care.

Results - Among patients with low literacy, intervention patients

were more likely than control patients to achieve goal.

Patients with higher literacy had similar odds of achieving

goal HbA1c levels regardless of intervention status.

Improvements in systolic blood pressure were similar by

literacy status.

Case2 Title AIDS Care. 2003 Feb;15(1):125-35.

A pilot study of the effects of a behavioural intervention on

treatment adherence in HIV-infected patients

Methodology 1) Individualized education about antiretroviral medication

and their side effects; positive reinforcement and

encouragement; individualized counseling weekly;

follow-up calls; and lifestyle assessment and the

identification of adherence barriers

Results - Enhanced adherence rates from a mean percentage of

80.27 at baseline to a mean of 97.5% at the end of follow-

up (six months time point)

Case3 Title BMJ 325 : 925 doi: 10.1136/bmj.325.7370.925 (Published 26

October 2002)

Interventions used in disease management programs for patients

with chronic illness which ones work? Meta-analysis of published

reports

Methodology 1) More than one intervention.

2) Provider education, feedback, and reminder

3) Patient education, reminders, and financial incentives

Results - Studied interventions were associated with improvements

in provider adherence to practice guidelines and disease

control

Table 2. Analysis of disease management in representative studies

In addition, several medical programs have carried out efficiently perceived

medication regimen under healthcare service provider education, feedback, and reminder. We

summarize three cases including interventions used in disease management programs.

Case1 Title JAMA, October 13, 2004—Vol 292, No. 14

Influence of Patient Literacy on the Effectiveness of a Primary

Care–Based Diabetes Disease Management Program

Methodology 3) Individualized communication, one-to-one educational

sessions including counseling and medication

management, helps manage glucose and cardiovascular

risks by allowing pharmacists to both initiate and titrate

blood pressure and glucose lowering medications,

including telephone reminders and, when needed,

addressing difficulties with transportation,

communication, and insurance.

4) Intervention by telephone or in person every 2 to 4 weeks

(more frequently if indicated). Communication to patients

was individualized using techniques that enhance

comprehension among patients with low literacy,

including predominantly verbal education with concrete,

simplified explanations of critical behaviors and goals;

“teach-back” to assess patient comprehension; and

picture-based materials. Main topics, revisited throughout

the follow-up period, included treatment goals,

identification of hypoglycemic and hyperglycemic

symptoms, prevention of long-term complications, and

self-care.

Results - Among patients with low literacy, intervention patients

were more likely than control patients to achieve goal.

Patients with higher literacy had similar odds of achieving

goal HbA1c levels regardless of intervention status.

Improvements in systolic blood pressure were similar by

literacy status.

Case2 Title AIDS Care. 2003 Feb;15(1):125-35.

A pilot study of the effects of a behavioural intervention on

treatment adherence in HIV-infected patients

Methodology 2) Individualized education about antiretroviral medication

and their side effects; positive reinforcement and

encouragement; individualized counseling weekly;

follow-up calls; and lifestyle assessment and the

identification of adherence barriers

Results - Enhanced adherence rates from a mean percentage of

80.27 at baseline to a mean of 97.5% at the end of follow-

up (six months time point)

Case3 Title BMJ 325 : 925 doi: 10.1136/bmj.325.7370.925 (Published 26

October 2002)

Interventions used in disease management programs for patients

with chronic illness which ones work? Meta-analysis of published

reports

Methodology 4) More than one intervention.

5) Provider education, feedback, and reminder

6) Patient education, reminders, and financial incentives

Results - Studied interventions were associated with improvements

in provider adherence to practice guidelines and disease

control

Case4 Title Womens Health (Larchmt). 2004 Jun;13(5):616-24.

Using success stories to share knowledge and lessons learned in

health promotion

Methodology 1) Community Change Chronicles were formed as a model

to develop success stories about WISEWOMAN(the Well-

Integrated Screening and Evaluation for Women Across

the Nation) projects.

Results - Use of the success stories by healthcare providers and

organizations gaining support for successful activities

Table 3. Representative Medical Programs to Improve Treatment or Medication

Adherence (Cutler et al. 2010)

We briefly explain how various medical programs promote adherence. In CCNC,

educated professionals practice coordination of care, and achieved a 5 to 7 % increase in

adherence rates. GHS implements electronic survey system to collect patients' medication

preferences. In GHS, monitoring patients' medication achieved a 5 to 7% reduction in

monthly costs. In the case of GHC, case managers educate patients and help them find more

affordable medication. As a result, GHC reduces more that $476 per patient.

II. A Discussion of Potential Factors for

Adherence

1. Self-determined motivation

We expect that potential factors for higher adherence in treatment or medication are

highly connected with personal motivation.

underlying the facilitating the higher level of adherence

self determination theory which

two reasons to take some actions: firstly, people expect to get reward such as praise, money,

and achievement of goals; secondly, they want to experience pos

love, happiness and fulfillment. In order to explain these reasons, we

theory.

Figure 1. The Self-Determination Continuum Showing Types of Motivation with Their

Regulatory Styles (Ryan and Deci

A Discussion of Potential Factors for Facilitating the Higher Level of

determined motivation

expect that potential factors for higher adherence in treatment or medication are

highly connected with personal motivation. Some wildly-held theories of motivation are

underlying the facilitating the higher level of adherence. In this proposal, we mainly

which is tested and produce positive outcomes. There are mainly

two reasons to take some actions: firstly, people expect to get reward such as praise, money,

and achievement of goals; secondly, they want to experience positive feelings that attribute to

lment. In order to explain these reasons, we adopt self

Determination Continuum Showing Types of Motivation with Their

(Ryan and Deci 2000)

Facilitating the Higher Level of

expect that potential factors for higher adherence in treatment or medication are

held theories of motivation are

In this proposal, we mainly describe

tested and produce positive outcomes. There are mainly

two reasons to take some actions: firstly, people expect to get reward such as praise, money,

itive feelings that attribute to

adopt self-determination

Determination Continuum Showing Types of Motivation with Their

Self-determination theory (Ryan and Deci 2000) proposed that intrinsic motivation

involves voluntarily taking part in an activity without external pressure. Engaging in many

behaviors attribute not to intrinsically rewarding but to helping individuals reach their self-

determined motivation. Both intrinsic motivation such as a tendency to find rewarding or fun

and identified motivation such as acting in accordance with one's values are associated with

positive psychological outcomes including enjoyment, attitudes, values, self-perceptions, and

intentions for future involvement. From these perspectives, we enlarge individual motivation

to individual disease management.

2. Factors affecting medication adherence

According to the World Health Organization, adherence is determined by the

interplay of five sets of factors: social/economic factors, provider-patient/healthcare system

factors, condition-related factors, therapy-related factors/ patient-related factors. In order to

investigate the classified factors, 2006 American Society on Aging and American Society of

Consultant pharmacists Foundation summarized a myriad of published studies.

1. SOCIAL AND ECONOMIC DIMENSION

Limited English language proficiency

Low health literacy

Lack of family or social support network

Unstable living conditions; homelessness

Burdensome schedule

Limited access to health care facilities

Lack of health care insurance

Inability or difficulty accessing pharmacy

Medication cost

Cultural and lay beliefs about illness and treatment

Elder abuse

2. HEALTH CARE SYSTEM DIMENSION

Provider-patient relationship

Provider communication skills (contributing to lack of

patient knowledge or understanding of the treatment

4. THERAPY-RELATED

DIMENSION

Complexity of medication regimen

(number of daily doses; number of

concurrent medications)

Treatment requires mastery of certain

techniques (injections, inhalers)

Duration of therapy

Frequent changes in medication

regimen

Lack of immediate benefit of therapy

Medications with social stigma

attached to use

Actual or perceived unpleasant side

effects

Treatment interferes with lifestyle or

requires significant behavioral changes

regimen)

Disparity between the health beliefs of the health care

provider and those of the patient

Lack of positive reinforcement from the health care

provider

Weak capacity of the system to educate patients and

provide follow-up

Lack of knowledge on adherence and of effective

interventions for improving it

Patient information materials written at too high

literacy level

Restricted formularies; changing medications covered

on formularies

High drug costs, copayments, or both

Poor access or missed appointments

Long wait times

Lack of continuity of care

3. CONDITION-RELATED DIMENSION

Chronic conditions

Lack of symptoms

Severity of symptoms

Depression

Psychotic disorders

Mental retardation/developmental disability

5. PATIENT-RELATED

DIMENSION

Physical Factors

Visual impairment

Hearing impairment

Cognitive impairment

Impaired mobility or dexterity

Swallowing problems

Psychological/Behavioral Factors

Knowledge about disease

Perceived risk/susceptibility to disease

Understanding reason medication is

needed

Expectations or attitudes toward

treatment

Perceived benefit of treatment

Confidence in ability to follow

treatment regimen

Motivation

Fear of possible adverse effects

Fear of dependence

Feeling stigmatized by the disease

Frustration with health care providers

Psychosocial stress, anxiety, anger

Alcohol or substance abuse

Figure 2. Factors Reported to Affect Adherence (2006 American Society on Aging and

American Society of Consultant Pharmacists Foundation)

These 5 categories enlighten how healthcare providers and government agencies

design their overcoming strategies to facilitate higher level of adherence. We discuss the

specific barriers and strategies at the next part.

III. A Discussion of How the Input from This Particular Case Could be

Implemented for Achieving Higher Level of Sticking to Medication

In order to make people “want” to do things they “have” to do, appropriate intervention

and education for patients are key strategies. Major predicts of poor adherence to medication

are presence of psychological problems, patient’s lack of belief in benefit of treatment, poor

provider-patient relationship, complexity of treatment, etc. In Chapter II, we categorized five

kinds of factors affecting medication adherence. In this chapter, we firstly introduce methods

of measuring adherence and then summarize how to solve the barriers in each dimension

based on the above five factors.

1. Methods of measuring adherence

Based on Osterberg and Blaschke(2005), there are direct and indirect methods to measure

adherence. Firstly, direct methods consist of directly observed therapy, measurement of the

level of medicine or metabolite in blood and measurement of the biologic marker in blood

which are accurate and objective methods used in clinical trials. However, these methods

sometimes require expensive quantitative assays and collection of bodily fluids. Secondly,

indirect methods include patient self-reports, rates of prescription refills, and electronic

medication monitors. Most of the methods are simple and easy to perform and obtain data. In

contrast, these methods are susceptible to errors due to data easily altered by the patients. In

the case of indirect methods of measuring adherence, facilitating higher medication

adherence is key to assess the patient's clinical response precisely.

2. Achieving higher level of medication adherence (Source: 2006 American Society

on Aging and American Society of Consultant Pharmacists Foundation)

1) Social and Economic Dimension

Social support is positively associated with medication adherence because people who

have social support from family, friends, or caregivers can be assisted with medication

regimen enabling better adherence to treatment.

Barriers Strategies

Burdensome schedule - Tailor medication regimen to daily routine

- Reminders or compliance aids

High cost or lack of availability

of transport to access pharmacy

- Mail order pharmacy

- Pharmacy delivery service

Medication cost - Switch to generics or lower-cost alternatives

- Refer to local programs or agencies that provide

medication assistance

- Pharmaceutical assistance programs

( www.helppatients.org )

- Enroll in Medicare Part D prescription drug plan

Cultural Belief - Establish a positive, supportive, trusting

relationship with the person

- Seek an understanding of the causes of illness

from the person's cultural point of view

- Elicit information about use of nontraditional

therapies in non-judgmental way

- Determine person's preference regarding group

learning or individual, private instruction

Table 4. Barrier and Strategies for Social and Economic Dimension

2) Healthcare System Dimension

A good relationship between patient and halthcare provider influences on high

medication adherence.

Barriers Strategies

Provider-patient relationship - Establish a positive, supportive, trusting

relationship with the patient

- Involve the patient in the decision-making process

- Assess the patient's understanding of the illness and

treatment

- Clearly communicate the benefits of treatment

- Involve the patient in setting treatment goals

- Assess the patient's readiness to carry out the

treatment plan

- Identify and discuss any barriers or obstacles to

adherence the patient may have and formulate

strategies for overcoming them with the patient

- Tailor medication regimens to the patient's daily

routine

- Reduce complexity of medication regimen

Provider communication - Adopt a friendly rather than a business-like attitude

- Spend some time conversing about nonmedical

topics

- Avoid medical jargon

- Use short words and short sentences

- Give clear instructions on the exact treatment

regimen, preferably in writing

- Repeat instructions

- Make advice as specific and detailed as possible

- Ask the patient to repeat what has to be done

Table 5. Barrier and Strategies for Healthcare System Dimension

3) Condition-Related Dimension

It is important to consider chronic condition and lack of symptoms for patients with

mental disabilities in order to achieve higher medication adherence.

Barriers Strategies

Therapy for asymptomatic

conditions

- Inform about disease process, importance of

treatment or prevention, and consequences if not

treated

Preventative therapies with no

immediately discernible benefit

- Preventative therapies with no immediately

discernible benefit

Chronic or long-term therapy - Simplify regimen

- Refer to support group

- Use reminder strategies

- Involve family members

- Cue medication taking to daily tasks or routine

Lack of belief in treatments’

effectiveness

- Discuss efficacy of medications

Fear of side effects - Review most common side effects

- Reinforce that most people do not have to stop

therapy because of side effects

- Reassure person that over time side effects should

be less of a problem

Patient-related - Cognitive therapy

- Education about the illness

- Education about the treatment

- Memory aids (phone reminders, alarms)

- Involvement in therapeutic alliance

Physician-related - Provide information on common side effects and

strategies to address

- Use of "patient-centered" approach

- Address patient's attitudes and beliefs about

medications

Social/Environment-related - Involve and educate family

- Improve access to mental health services (case

management, home visits, convenient clinic hours

and locations)

- More attractive clinic environment

- Improved coordination between service providers

Treatment-related - Minimize complexity of medication regimen

- Titration to optimum dose

- Provide clear instructions on medication use

- Minimize impact of side effects

- Select medication with fewer side effects

Table 6. Barrier and Strategies for Condition-Related Dimension

4) Therapy-Related Dimension

Barriers Strategies

Complexity of medication

regimen (number of daily doses;

number of concurrent

medications)

- Identify and discontinue unnecessary medications

- Reduce dose frequency for medications where

possible; use long-acting dosage forms where

possible

- Identify combination medications that can replace

two separate prescriptions

- Identify opportunities to use one drug to treat

more than one medical condition

- Identify medications prescribed to treat the side

effects of other medications

- Introduce reminder strategies tailored to the

individual, such as pill organizers, calendars,

phone reminder systems, etc.

- Provide updated written list of medications

Lack of immediate benefit of

therapy

- Educate about what to expect from treatment (e.g., how medication works, time to onset of effect, expected goals of therapy, how to monitor for effectiveness)

Chronic or long-term therapy - Simplify regimen

- Refer to support group

- Use reminder strategies

- Involve family members

- Cue medication taking to daily tasks or routine

Actual or perceived unpleasant

side effects

- Educate about what to expect from treatment and

risks vs. benefits (e.g., tolerance might develop to

certain side effects)

- Suggest ways to manage minor side effects

- Identify alternative medications with less side

effect potential

General treatment regimen

concerns

- Explore preferences and issues with treatment

regimen:

- Does person believe treatment is needed or

effective?

- Does person want to use medicine to treat

condition?

- Does person have concerns about long-term

treatment?

- Involve person in determining goals of therapy

- Address medication-related issues that make

adherence difficult, such as the need to master

specific administration techniques (e.g., injections,

inhalers)

Table 7. Barrier and Strategies for Therapy-Related Dimension

5) Patient-Related Dimension

Poor medication adherence is sometimes attributed to lack of knowledge about the

disease and lack of motivation, and low self-efficacy. A person's perception of the danger

posed by their disease may influence on medication adherence.

Barriers Strategies

Knowledge - Identify "knowledge gaps"

- Provide information where gaps exist

- Confirm understanding; have person repeat the

information

- Demonstrate any special techniques for use of

devices for administering medication

- Ask about any concerns the person has about using

the medicine

- Provide appropriate written information

- Follow up for reinforcement of the information

provided

Motivation - Use motivational interviewing techniques for

people in the precontemplation and contemplation

stages of change

- "Roll" with resistance

- Involve person in problem solving

- Provide information and alternatives

- Express empathy

- Avoid argumentation

- Develop discrepancy between the person's behavior

and important personal goals

- Involve family members

- Refer to support group

Self-Efficacy - Use motivational interviewing techniques to

enhance the person's confidence in their ability to

overcome barriers and succeed in change

- Recognize small positive steps the person is taking

- Use supportive statements

- Help person set reasonable and reachable goals

- Express belief that person can achieve goals

Table 8. Barrier and Strategies for Patient-Related Dimension

Conclusion

The current knowledge and evidence regarding treatment or medication adherence

suggest that healthcare providers should understand the patients' experience and expectations

to build partnerships. The effort to help patients understand their status enables the

individuals to make a reasonable decision to achieve timely treatment or medication.

Building a relationship on trust and timely intervention and education for patients are the best

course of helping people to stick to their routines.

Reference

Steven Baroletti et al., Medication Adherence in Cardiovascular Disease, Circulation.

2010-Vol 121: 1455-1458

Barry Berman, Developing an Effective Customer Loyalty Program, California

Management Review. 2000 Fall Vol 49: 143-148

Russel L. et al., Influence of Patient Literacy on the Effectiveness of a Primary Care–

Based Diabetes Disease Management Program, JAMA. October 13, 2004—Vol 292, No. 14

Molassiotis A. et al., A pilot study of the effects of a behavioural intervention on

treatment adherence in HIV-infected patients, AIDS Care. 2003 Feb;15(1):125-35

Weingarten SR et al., Interventions used in disease management programs for

patients with chronic illness which ones work? Meta-analysis of published reports, BMJ 325 :

925 doi: 10.1136/bmj.325.7370.925 (Published 26 October 2002)

Cutler et al., Perspective Thinking Outside the Pillbox: Medication Adherence as a

Priority Care Reform, The New England Journal of Medicine,2010; 362:1553-155

Power et al., Obesity, cardiovascular fitness, and physically active adolescents’

motivations for activity: A self-determination theory approach, Psychology of Sport and

Exercise Volume 12, Issue 6, November 2011

R.M. Ryan and E.L. Deci, Self-determination theory and the facilitation of intrinsic

motivation, social development, and well-being. American Psychologist, 55 (2000), pp. 68–

78.

Lewis SD et al., Using success stories to share knowledge and lessons learned in

health promotion. Womens Health (Larchmt). 2004 Jun;13(5):616-24.

Web Resources Customer Loyalty Program That Works http://hbswk.hbs.edu/item/6733.html

Adult MEDUCATION (2006 American Society on Aging and American Society of

Consultant Pharmacists Foundation) http://www.adultmeducation.com/index.html