More than good intentions: advancing adherence to therapy recommendations.

Mary Vining Radomski, PhD, OTR/L, FAOTA, is Clinical Scientist, Sister Kenny Research Center, 800 East 28th Street, Minneapolis, MN 55407; Mary. [email protected] E veryone who has tried to change their behavior can appreciate the difficulties in sustaining this effort despite their best intentions. Imagine, then, the effort required to adhere to occupational therapy recommendations after the onset of disability when the associated everyday changes are not necessarily of one’s own choosing. Many people who receive occupational therapy services face this scenario, especially those with chronic health conditions. Many patients with stroke, brain injury, and spinal cord injury do not follow discharge recommendations or prescribed therapy protocols (Andrews & Stewart, 1979; Ditor et al., 2003;O’Brien&Bailey, 2008; Schönberger, Humle, Zeeman, & Teasdale, 2006; Wallenbert & Jonsson, 2005) even though doing so is associated with optimal outcomes of care (Clay & Hopps, 2003). The rates of nonadherence to chronic illness regimens are estimated at 30%–60%, which is significantly worse than those for acute illness treatments (Christensen, 2004). Despite the evidence that people with chronic health conditions may not adhere to their health care providers’ recommendations, the issue of nonadherence remains largely ignored by occupational therapy clinicians and researchers. The term itself is omitted from the profession’s official vocabulary (American Occupational Therapy Association [AOTA], 2008), and the enterprise is not represented in conceptualizations of the service delivery process (AOTA, 2008). Occupational therapy research is equally lacking in this area. A small number of publications have primarily focused on adherence as a secondary or ancillary issue; few studies have specifically examined adherence-promoting strategies. Moreover, this gap in occupational therapy adherence research was not specifically mentioned in the recently developed AOTA/American Occupational Therapy Foundation research agenda (AOTA, 2009). The purpose of this report is to bring the problem of nonadherence into the occupational therapy professional fold and clinical conversation. To that end, I describe the complexities associated with adherence to medical recommendations and summarize the small literature specific to adherence and occupational therapy. I use an ecological model of adherence in rehabilitation to propose adherence-promoting strategies for clinicians and conclude with directions for occupational therapy research.