1. ADHERENCE (COMPLIANCE) Kai-Lit Phua, PhD FLMI Associate Professor School of Medicine & Health Sciences Monash University Malaysia

2. Biographical Details Kai-Lit Phua received his BA (cum laude) in Public Health & Population Studies from the University of Rochester and his PhD in Sociology (Medical Sociology) from Johns Hopkins University. He also holds professional qualifications from the insurance industry. Kai-Lit Phua received his BA (cum laude) in Public Health & Population Studies from the University of Rochester and his PhD in Sociology (Medical Sociology) from Johns Hopkins University. He also holds professional qualifications from the insurance industry. Prior to joining academia, he worked as a research statistician for the Maryland Department of Health and Mental Hygiene and for the Managed Care Department of a leading insurance company in Singapore. Prior to joining academia, he worked as a research statistician for the Maryland Department of Health and Mental Hygiene and for the Managed Care Department of a leading insurance company in Singapore. He was awarded an Asian Public Intellectual Senior Fellowship by the Nippon Foundation in 2003. He was awarded an Asian Public Intellectual Senior Fellowship by the Nippon Foundation in 2003.

3. NONADHERENCE This simply means failure of a patient to follow medical instructions and advice EXAMPLES: Patient does not take his or her medicine at all Patient does not take his or her medicine at all Improper dosages are taken Improper dosages are taken The medicine is taken along with unprescribed drugs (including traditional medicine). This can lead to adverse interactions. The medicine is taken along with unprescribed drugs (including traditional medicine). This can lead to adverse interactions. Not following advice on nutrition e.g. during pregnancy and lactation Not following advice on nutrition e.g. during pregnancy and lactation

4. NONADHERENCE Nonadherence is widespread (some estimates go as high as 50%!) The consequences can be serious e.g. diabetes mellitus, hypertension

5. FACTORS AFFECTING NONADHERENCE Personality of the patient e.g. some patients like to “rebel against authority”, denial of disease Personality of the patient e.g. some patients like to “rebel against authority”, denial of disease Poor quality of doctor-patient interaction Poor quality of doctor-patient interaction Cognitive factors e.g. forgetting, unclear instructions, too complex medications, careless Cognitive factors e.g. forgetting, unclear instructions, too complex medications, careless Uncomfortable side effects Uncomfortable side effects Drugs are too expensive (patient tries to “stretch” the medicine by skipping a dose) Drugs are too expensive (patient tries to “stretch” the medicine by skipping a dose) Patient frustration with being dependent on drug Patient frustration with being dependent on drug “Testing” by the patient “Testing” by the patient Food taboos and beliefs – sickness, pregnancy, lactation, menstruation Food taboos and beliefs – sickness, pregnancy, lactation, menstruation

6. STEPS TO IMPROVE ADHERENCE Give clear and simple instructions Give clear and simple instructions Better doctor-patient communication and interaction (emphasise, repeat, be specific, etc.) Better doctor-patient communication and interaction (emphasise, repeat, be specific, etc.) Simplify the regimen if possible Simplify the regimen if possible Prescribe cheaper generic drugs in place of expensive, branded drugs Prescribe cheaper generic drugs in place of expensive, branded drugs Inform patient about possible side effects Inform patient about possible side effects Change the medication if severe side effects Change the medication if severe side effects Explain about taking antibiotics properly Explain about taking antibiotics properly Get family members to monitor adherence Get family members to monitor adherence Doctor can also monitor adherence Doctor can also monitor adherence Deal with food taboos and beliefs Deal with food taboos and beliefs

7. REMEMBER! Partial adherence is better than total nonadherence Important to educate patients about taking antibiotics properly i.e. take the entire course Be especially careful when prescribing to children, the elderly, and the immunocompromised Look out for serious side effects, adverse reactions and adverse interactions!

8. THE END THANK YOU