In the work I’ve done with medication adherence, there are several “usual suspects” we find behind people’s failure to take drugs as prescribed. Issues related to habit and routine are common; I know my own medication habits become significantly worse when I’m traveling a lot. We also see non-adherence due to a lack of education or understanding of proper drug use, or inability to effectively communicate with providers.
We do find that emotional issues, such as a negative reaction to having a particular diagnosis, can drive some people’s non-adherence. Related to that, an issue with medication adherence that I think is under-explored is how people’s sense of personal identity affects their willingness to take certain medications. Simply put, I don’t think today’s relatively young 50- and 60-year olds feel emotionally ready to take the medications that come with many chronic condition diagnoses.
I saw this dynamic in India when I was working on a project there for people with diabetes. There was a prevalent cultural belief that insulin was an end-of-life drug, only for the very ill diabetic patient. Therefore, newly diagnosed patients, who often exhibit few symptoms and still feel pretty good, would resist using insulin to treat their diabetes. At the time I did my research, India was primarily using a cash-pay health care system where costs were paid in full by the patient. This created a much more consumer-oriented approach toward health care, where dissatisfied patients would take their business elsewhere. A dangerous cycle was in progress where patients who were recommended insulin use for their diabetes did not return to the offending doctor, leading fewer doctors to prescribe insulin. At the same time, as people’s diabetes was poorly controlled, insulin indeed became more of a drug for the very ill.
I believe a less extreme version of this dynamic takes place in the United States, as the idea of what it means to grow older changes. If 30 is the new 20 (actually a very controversial idea!), then 60 is the new 40. Today’s 60 year olds are not old the way the 60 year olds of a generation ago were. They’re continuing to work, they’re technologically connected, and they’re probably feeling a little jarred by the thought that they may need “old people” drugs. You know the ones: heart pills, high blood pressure medications, stool softeners. These drugs may not fit with the young self-image today’s 50- and 60-somethings have, thereby decreasing interest in taking the medications below an already worrying baseline adherence rate.
Interestingly, I don’t think this failure to take prescribed medications that don’t adhere to personal identity necessarily translates to a lack of interest in health. I think many of the people age 60 and under who resist taking a prescription medication for a chronic condition like high cholesterol or blood pressure are quite willing to attempt lifestyle changes instead. Unfortunately, those don’t always translate to successful outcomes.
In some ways, this all gets back to that idea of autonomy or personal volition in motivating health behavior change. I think of autonomy as our need to write our own story, at least somewhat. If I’m telling a story in which I’m young and vibrant, but then my doctor tells me I need to be on a daily or weekly medication that I see as being more appropriate for an octogenarian, then I may not write it into my story. It’s easier to write a new exercise habit in, or an addiction to kale and organic yogurt. The challenge is to help people zoom out enough to see the medication as part of their health behavior repertoire, rather than focusing in on the details that make them feel old or not like themselves. And hey, maybe some rebranding would help too.