A meta-analysis 2 evaluated the use of cognitive-based behaviour change techniques (CBCT) as interventions to improve medication adherence. 26 randomised controlled trials (n=5216) were included. Interventions most commonly used motivational interviewing (MI) (42.3% of studies), but many used techniques such as aiming to increase the patient's confidence and sense of self-efficacy, encouraging support-seeking behaviours and challenging negative thoughts, which were not specifically categorised. Interventions were most commonly delivered from community-based settings by routine healthcare providers. The intervention period ranged from 4 studies (15.4%) reporting singular sessions, to 6 studies (23.1%) reporting multiple sessions over 12 months. The comparison group was ‘standard care' for all studies; for 13 studies (50%), standard care involved some form of technique to improve adherence such as education, encouragement or provision of adherence aids and in these studies, recipients of the intervention received further techniques such as MI. Cognitive-based behaviour change techniques were more effective than standard care (effect size 0.34, 95% CI 0.23 to 0.46; 26 trials, heterogeneity [I²]=68%). Adjustment for publication bias generated a more conservative estimate of summary effect size of 0.21 (95% CI 0.08 to 0.33).
Another meta-analysis 3 evaluated effectiveness of MI on medication adherence in adults with chronic diseases. 19 RCTs were identified, and 16 were included in the meta-analysis. The pooled MI intervention effect size was 0.12 (95% CI 0.05 to 0.20, I²= 1%). Interventions that were based on MI only (β = 0.183, 95% CI 0.004 to 0.362) or those in which interventionists were coached during intervention implementation (β = 0.465, 95% CI 0.028 to 0.902) were the most effective. MI interventions that were delivered solely face to face were more effective than those that were delivered solely by phone.
Yet another meta-analysis 4 evaluated effectiveness of MI on medication adherence including17 RCTs that compared MI to a control group. 1Ten targeted adherence to HIV medication. For studies reporting a categorical measure (n = 11), the pooled RR for medication adherence was higher for MI compared with control (RR 1.17, 95 % CI 1.05 to 1.31; p < 0.01). For studies reporting a continuous measure (n = 11), the pooled SMD for medication adherence was positive (SMD 0.70, 95 % CI 0.15 to -1.25; p < 0.01) for MI compared with control. The characteristics that were significantly (p < 0.05) associated with medication adherence were telephonic MI and fidelity-based feedback.
A systematic review 5 included 54 RCTs. The MI interventions were delivered alone or in combination with other interventions, and varied in mode of delivery (e.g. face-to-face, phone), exposure level (duration, number of sessions), and provider characteristics (profession, training). Medication adherence showed significant improvement in 23 RCTs, and other clinical outcomes were improved in 19 RCTs (e.g. risky behaviors, disease symptoms).
A Cochrane review [Abstract] 1 included 182 studies. These included 11 studies in hypertension, 10 in schizophrenia or acute psychosis, and 11 in asthma (and / or chronic obstructive pulmonary disease COPD). For short-term treatments, 4 of ten interventions reported in 9 RCTs showed an effect on both adherence and at least one clinical outcome. For long-term treatments, 36 of 81 interventions reported in 69 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.
Comment: The quality of evidence was downgraded by study quality (lack of blinding of the outcome assessment in most of studies) and by heterogeneity in some studies.
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