Journal of Pediatric Psychology, Vol. 26, No. 5, 2001, pp. 283-284
© 2001 Society of Pediatric Psychology
Book Review
Promoting Adherence to Medical Treatment in Chronic Childhood Illness: Concepts, Methods, and Interventions
The Children's Hospital of Philadelphia
This unique selection of papers collected in book format presents an engrossing discussion of theoretical perspectives, assessment methods, and intervention issues that affect adherence to medical regimen in the pediatric population. While incorporating scientific findings, the book meshes perspectives and opinions of specialists in anthropology, pediatrics, psychology, and sociology. The insight and experience of these pediatric experts are offered with a vision for improving future adherence work. Despite its sober recognition of the current state of affairs and complexities of adherence work, an optimistic attitude sets the tone for this publication. The book may appear lengthy due to its comprehensive coverage, but do not get discouraged by its size. Each section is tied together thematically, and each chapter is written concisely.
In the section on "Historical Foundations," Trostle underlines the slow but steady development of the definitions and conceptual underpinnings of "adherence" by placing patient choices and their actions in medical situations in historical and social contexts. The discussion is helpful to understand the multiple determinants of families' ability to manage their illness regimen. For example, Korsch and Marcy emphasize the important role of physician-patient communication in enhancing adherence, and this theme is intertwined throughout the writings of the book. The authors of this section also set the stage for the empowerment of the patient to become an active participant in their complex and demanding treatment course.
Rather than summarizing the application of various theoretical models to adherence, the section on "Conceptual Models" gives a more conceptual perspective in teasing apart types and forms of adherence. For example, Bauman provides a useful differentiation between volitional and inadvertent nonadherence. Different processes underlie these types of adherence, different risk factors come into play, and, therefore, different interventions would be necessary to promote adherence for patients characterized by these concepts. Another perspective is provided by Creer, who suggests specific elements for effective "self-management" of chronic illness, which include goal setting, information collection, processing and evaluation, decision making, action, and self-reaction. Although the discussion of the critical components of adherence vary somewhat, Creer's idea that the health care professional, the patient/family system, and the disease/regimen characteristics must come together like a puzzle to promote a successful outcome is a common theme throughout the book.
The section called "Measurement Issues" begins with a general overview by Matsui of the measurement challenges inherent in this work. Rather than simply focusing on delayed or omitted forms of adherence, she brings attention to the intricacies of measuring adherence by addressing errors in dose amount, interval between doses, medicine substitution, and premature termination by the patient. The two chapters that follow discuss critical issues in assessment and measurement related to specific chronic illnesses of asthma (Bender, Milgrom, Wamboldt, & Rand) and diabetes (Delamater). Since these conditions are often studied, they tend to serve as models for professionals working with other pediatric populations. The authors highlight seminal studies conducted with their respective populations before embarking on a discussion of the commonly used assessment tools. Although painting a balanced view of advantages and limitations of each measure, the authors present the 24-hour recall as the most promising and comprehensive tool available. The authors emphasize the need to rely on multiple methods and informants, and they urge continued refinement of measurement techniques.
Access to health services may be delayed or denied because the utilization of services required by chronically ill children may exceed the allotted costs. A crucial chapter in the "Influences on Treatment Adherence" section by Walders, Nobile, and Drotar brings to the forefront some of the challenges that arise in the treatment of chronic illness within the managed care system—preclusion of an accurate and comprehensive assessment of adherence, compromise of the patient-physician relationship, and separation of the mental health services from the patient's medical team; all of which create further barriers to adherence. The authors conclude with suggestions for patient advocacy and research applications to alter this serious dilemma. DiMatteo delves into the complexities of patient/family-practitioner communication. She addresses multifaceted aspects such as patient beliefs and attitudes about the efficacy of treatment, psychological barriers and available support systems, and the trust and respect established between the patient/family and the medical team. In a related topic, Ievers-Landis and Drotar focus on the necessary, though usually not sufficient component of adherence: knowledge of the treatment regimen. They offer factors that affect the level of understanding and discuss empirical research for enhancing patient knowledge of their regimen.
In the "Impact of Treatment Adherence" section, Varni, Jacobs, and Seid, using the PedsQL, present an integrated conceptual model of treatment adherence and health-related quality of life. Varni's model addresses the relative contribution of health-related knowledge, attitudes, skills, and problem solving on patient's adherence. Of particular importance—and consistent with the theme of the book—his model supports the notion that the health care team has a significant impact on patient adherence. The chapter that follows has a unique quality in that it addresses an issue often over-looked but of great interest to scientists. Johnson urges researchers to use error resulting from less than optimal adherence in clinical trials as something to be studied rather than controlled statistically. She makes a convincing argument for difficulties inherent in "intent-to-treat" analyses. The error source, she proposes, provides rich data that should not be discarded.
The section that addresses "Intervention" to promote adherence has much to offer the reader. These treatment studies span populations of diabetes (Anderson, Brackett, Ho, & Laffel; Wysocki, Greco, Harris, & White), cystic fibrosis (Quittner, Drotar, Ievers-Landis, Slocum, Seidner, & Jacobsen; Stark), juvenile rheumatoid arthritis (Rapoff), and growth hormone deficiency (Sandberg, Mazur, Hazen, Alliger, Buchlis, & MacGillivray). They serve as models for researchers developing adherence programs with understudied populations. The scope of the interventions tends to focus on behavioral and family-systems orientations. The strength of this section is that the authors do not simply summarize the existing treatment outcome studies; they describe the caveats of the interventions designed and implemented by their research groups. The challenges that most of us face are brought to the fore-front with an educational, collegial, and optimistic tone. The authors are specific enough for the reader to gain an understanding of the practical aspects of the interventions, allowing for future replication, modification, and generalization to other chronic illness. With hindsight bias, the experts note the challenges and wrinkles that were to be ironed out and that will need continued modification.
Overall, this book is an excellent resource for researchers who wish to understand the complexities of adherence and initiate research projects in this area. The authors share insights backed by scientific data that provide interesting food for thought and expert guidance for future investigations. The papers presented in this book are well integrated and intertwined with common threads but are unique because they each point to varying facets of adherence. Clinical implications are addressed to a lesser extent, making this reading somewhat less useful for clinicians. This publication, edited by Dennis Drotar, is a significant next step in the continued struggle for promoting adherence to medical regimen and is enthusiastically recommended for professionals working with chronically ill children and their families.
Notes
Edited by Dennis Drotar. Mahwah, NJ: Lawrence Erlbaum Associates, 2000. 536 pp. $110.00.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||