Patient-by-treatment context interaction in chronic disease: a conceptual framework for the study of patient adherence

OBJECTIVE: Previous reviews have concluded that there is little or no evidence supporting a predictable association between patient characteristics and regimen adherence in chronic illness. The primary objective of this article is to propose an alternative conceptual framework for the interpretation and design of adherence research. METHODS: The author's research involving adherence among patients with end-stage renal disease is reviewed and used to illustrate the patient-by-context interactive framework. RESULTS: Adherence is most favorable when the patient's characteristic or preferred style of coping with illness and treatment-related experiences is congruent with the contextual features or demands of the particular type of medical intervention the patient is undergoing. Among patients with end-stage renal disease, a more vigilant or active style of coping is associated with more favorable adherence only for patients undergoing home-based dialysis treatment modalities that are highly patient directed. Among patients receiving hospital-based, provider-controlled treatment, a less vigilant or more passive coping style is associated with more favorable dialysis regimen adherence. CONCLUSIONS: The patient-by-context interactive perspective can provide a useful framework for the interpretation and design of adherence research.