Psychological Techniques to Promote Adherence

  • Monica Shah
  • Felicia Tai
  • Abigail Cline
  • Adrian PonaEmail author
  • E. J. Masicampo
  • Steven R. Feldman
Part of the Updates in Clinical Dermatology book series (UCD)


Adherence is a multifaceted behavioral process involving individuals, families, medical providers, communities, and health-care systems. Each of these factors represents a target for behavioral interventions to improve patient adherence. This chapter will describe adherence interventions centred on psychological principles of patients, health care providers, and health systems. Patient-based psychological approaches involve developing self-management techniques, or learning how particular behaviors associate with a health outcome, such as cognitive behavioral therapy. Physician-based strategies involve using motivational interviewing to help patients better understand their behavior and its consequences, or developing a sense of accountability in the patient-provider relationship. System-based approaches include scheduling longer appointment times, continuity of care, and communication with patients. Psychology offers useful theories, models, and strategies to promote practical strategies to promote adherence in patients suffering from chronic dermatological conditions.


Adherence Compliance Dermatology Educational interventions Intentional nonadherence Unintentional nonadherence 


Conflicts of Interest

Dr. Steven R. Feldman is a speaker for Taro. He is a consultant and speaker for Galderma, Abbvie, Celgene, Abbott Labs, Lilly, Janssen, Novartis Pharmaceuticals and Leo Pharma Inc. Dr. Feldman has received grants from Galderma, Janssen, Abbott Labs, Abbvie, Celgene, Taro, Sanofi, Celgene, Novartis Pharmaceuticals, Qurient, Pfizer Inc. and Anacor. He is a consultant for Advance Medical, Caremark, Gerson Lehrman Group, Guidepoint Global, Kikaku, Lilly, Merck & Co Inc., Mylan, Pfizer Inc., Qurient, Sanofi, Sienna, Sun Pharma, Suncare Research, Valeant, and Xenoport. Dr. Feldman is the founder, chief technology officer and holds stock in Causa Research. Dr. Feldman holds stock and is majority owner in Medical Quality Enhancement Corporation. He receives Royalties from UpToDate, Informa and Xlibris.

Dr. Adrian Pona, Dr. Abigail Cline, Dr. Masicampo, Monica Shah, and Felicia Tai have no conflicts of interest to disclose.


  1. 1.
    Wright S. Patient satisfaction in the context of cancer care. Ir J Psychol. 1998;19(2–3):274–82.CrossRefGoogle Scholar
  2. 2.
    Godding V, Kruth M, Jamart J. Joint consultation for high-risk asthmatic children and their families, with pediatrician and child psychiatrist as co-therapists: model and evaluation. Fam Process. 1997;36(3):265–80.CrossRefPubMedGoogle Scholar
  3. 3.
    Miller TA, Dimatteo MR. Importance of family/social support and impact on adherence to diabetic therapy. Diabetes Metab Syndr Obes. 2013;6:421–6.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Cockburn J, Thompson SC, Marks R, Jolley D, Schofield P, Hill D. Behavioural dynamics of a clinical trial of sunscreens for reducing solar keratoses in Victoria, Australia. J Epidemiol Community Health. 1997;51(6):716–21.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ. 1995;153(10):1423–31.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Smiddy MP, O’Connell R, Creedon SA. Systematic qualitative literature review of health care workers’ compliance with hand hygiene guidelines. Am J Infect Control. 2015;43(3):269–74.CrossRefPubMedGoogle Scholar
  7. 7.
    McAleer MA, Mason DL, Cunningham S, O’Shea SJ, McCormick PA, Stone C, et al. Alcohol misuse in patients with psoriasis: identification and relationship to disease severity and psychological distress. Br J Dermatol. 2011;164(6):1256–61.CrossRefPubMedGoogle Scholar
  8. 8.
    Murota H, Takeuchi S, Sugaya M, Tanioka M, Onozuka D, Hagihara A, et al. Characterization of socioeconomic status of Japanese patients with atopic dermatitis showing poor medical adherence and reasons for drug discontinuation. J Dermatol Sci. 2015;79(3):279–87.CrossRefPubMedGoogle Scholar
  9. 9.
    Neri L, Peris K, Longo C, Calvieri S, Frascione P, Parodi A, et al. Physician-patient communication and patient-reported outcomes in the actinic keratosis treatment adherence initiative (AK-TRAIN): a multicenter, prospective, real-life study of treatment satisfaction, quality of life and adherence to topical field-directed therapy for the treatment of actinic keratosis in Italy. J Eur Acad Dermatol Venereol. 2019;33(1):93–107.CrossRefPubMedGoogle Scholar
  10. 10.
    Kazemi T, Sachsman SM, Wilhalme HM, Goh C. Isotretinoin therapy: a retrospective cohort analysis of completion rates and factors associated with nonadherence. J Am Acad Dermatol. 2018;79(3):571–3.CrossRefPubMedGoogle Scholar
  11. 11.
    Craşovan DI, Sava FA. Translation, adaptation, and validation on Romanian population of COPE questionnaire for coping mechanisms analysis. Cogn Brain Behav. 2013;17(1):61–76.Google Scholar
  12. 12.
    Kasparian NA, McLoone JK, Butow PN. Psychological responses and coping strategies among patients with malignant melanoma: a systematic review of the literature coping strategies and patients with melanoma. Arch Dermatol. 2009;145(12):1415–27.CrossRefPubMedGoogle Scholar
  13. 13.
    Kirby JS, Sisic M, Tan J. Exploring coping strategies for patients with hidradenitis suppurativa coping strategies for patients with hidradenitis suppurativa letters. JAMA Dermatol. 2016;152(10):1166–7.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Wahl A, Hanestad BR, Wiklund I, Moum T. Coping and quality of life in patients with psoriasis. Qual Life Res. 1999;8(5):427–33.CrossRefPubMedGoogle Scholar
  15. 15.
    Fawzy FI, Cousins N, Fawzy NW, Kemeny ME, Elashoff R, Morton D. A structured psychiatric intervention for cancer patients. I. Changes over time in methods of coping and affective disturbance. Arch Gen Psychiatry. 1990;47(8):720–5.CrossRefPubMedGoogle Scholar
  16. 16.
    Papava I, Oancea C, Enatescu VR, Bredicean AC, Dehelean L, Romosan RS, et al. The impact of coping on the somatic and mental status of patients with COPD: a cross-sectional study. Int J Chron Obstruct Pulmon Dis. 2016;11:1343–51.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Albai A, Sima A, Papava I, Roman D, Andor B, Gafencu M. Association between coping mechanisms and adherence to diabetes-related self-care activities: a cross-sectional study. Patient Prefer Adherence. 2017;11:1235–41.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Beck JS. Cognitive behavior therapy: basics and beyond: New York: Guilford Press; 2011.Google Scholar
  19. 19.
    Sudak DM. CBT in patients with chronic illness. Psychiatr News. 2017;52:1.CrossRefGoogle Scholar
  20. 20.
    Jung J, Hwang EJ. Do patients with acne need cognitive behavioral therapy? An analysis of patient knowledge and behavior. Int J Dermatol. 2012;51(11):1319–24.CrossRefPubMedGoogle Scholar
  21. 21.
    Zachariae R, Oster H, Bjerring P, Kragballe K. Effects of psychologic intervention on psoriasis: a preliminary report. J Am Acad Dermatol. 1996;34(6):1008–15.CrossRefPubMedGoogle Scholar
  22. 22.
    Fortune DG, Richards HL, Kirby B, Bowcock S, Main CJ, Griffiths CE. A cognitive-behavioural symptom management programme as an adjunct in psoriasis therapy. Br J Dermatol. 2002;146(3):458–65.CrossRefPubMedGoogle Scholar
  23. 23.
    Fortune DG, Richards HL, Kirby B, McElhone K, Main CJ, Griffiths CE. Successful treatment of psoriasis improves psoriasis-specific but not more general aspects of patients’ well-being. Br J Dermatol. 2004;151(6):1219–26.CrossRefPubMedGoogle Scholar
  24. 24.
    Bundy C, Pinder B, Bucci S, Reeves D, Griffiths CE, Tarrier N. A novel, web-based, psychological intervention for people with psoriasis: the electronic Targeted Intervention for Psoriasis (eTIPs) study. Br J Dermatol. 2013;169(2):329–36.CrossRefPubMedGoogle Scholar
  25. 25.
    van Beugen S, Ferwerda M, Spillekom-van Koulil S, Smit JV, Zeeuwen-Franssen MEJ, Kroft EBM, et al. Tailored therapist-guided internet-based cognitive behavioral treatment for psoriasis: a randomized controlled trial. Psychother Psychosom. 2016;85(5):297–307.CrossRefPubMedGoogle Scholar
  26. 26.
    Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-management approaches for people with chronic conditions: a review. Patient Educ Couns. 2002;48(2):177–87.CrossRefPubMedGoogle Scholar
  27. 27.
    Son HK, Lim J. The effect of a web-based education programme (WBEP) on disease severity, quality of life and mothers’ self-efficacy in children with atopic dermatitis. J Adv Nurs. 2014;70(10):2326–38.CrossRefPubMedGoogle Scholar
  28. 28.
    Ersser SJ, Farasat H, Jackson K, Gardiner E, Sheppard ZA, Cowdell F. Parental self-efficacy and the management of childhood atopic eczema: development and testing of a new clinical outcome measure. Br J Dermatol. 2015;173(6):1479–85.CrossRefPubMedGoogle Scholar
  29. 29.
    Mitchell AE, Fraser JA. Parents’ self-efficacy, outcome expectations, and self-reported task performance when managing atopic dermatitis in children: instrument reliability and validity. Int J Nurs Stud. 2011;48(2):215–26.CrossRefPubMedGoogle Scholar
  30. 30.
    Armstrong AW, Kim RH, Idriss NZ, Larsen LN, Lio PA. Online video improves clinical outcomes in adults with atopic dermatitis: a randomized controlled trial. J Am Acad Dermatol. 2011;64(3):502–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Santer M, Muller I, Yardley L, Burgess H, Selinger H, Stuart BL, et al. Supporting self-care for families of children with eczema with a web-based intervention plus health care professional support: pilot randomized controlled trial. J Med Internet Res. 2014;16(3):e70.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    van Os-Medendorp H, van Leent-de Wit I, de Bruin-Weller M, Knulst A. Usage and users of online self-management programs for adult patients with atopic dermatitis and food allergy: an explorative study. JMIR Res Protoc. 2015;4(2):e57.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Ersser SJ, Cowdell F, Latter S, Gardiner E, Flohr C, Thompson AR, et al. Psychological and educational interventions for atopic eczema in children. Cochrane Database Syst Rev. 2014;1:CD004054.Google Scholar
  34. 34.
    Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191–215.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Lorig KR, Sobel DS, Stewart AL, Brown BW Jr, Bandura A, Ritter P, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care. 1999;37(1):5–14.CrossRefPubMedGoogle Scholar
  36. 36.
    Ersser SJ, Cowdell FC, Nicholls PG, Latter SM, Healy E. A pilot randomized controlled trial to examine the feasibility and efficacy of an educational nursing intervention to improve self-management practices in patients with mild-moderate psoriasis. J Eur Acad Dermatol Venereol. 2011;26(6):738–45.CrossRefPubMedGoogle Scholar
  37. 37.
    Jackson K, Ersser SJ, Dennis H, Farasat H, More A. The eczema education Programme: intervention development and model feasibility. J Eur Acad Dermatol Venereol. 2014;28(7):949–56.CrossRefPubMedGoogle Scholar
  38. 38.
    Thorneloe RJ, Bundy C, Griffiths CEM, Ashcroft DM, Cordingley L. Nonadherence to psoriasis medication as an outcome of limited coping resources and conflicting goals: findings from a qualitative interview study with people with psoriasis. Br J Dermatol. 2017;176(3):667–76.CrossRefPubMedGoogle Scholar
  39. 39.
    National Collaborating Centre for Primary C. National Institute for Health and Clinical Excellence: Guidance. Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence. London: Royal College of General Practitioners (UK); 2009.Google Scholar
  40. 40.
    Higginson S, Mansell W, Wood AM. An integrative mechanistic account of psychological distress, therapeutic change and recovery: the perceptual control theory approach. Clin Psychol Rev. 2011;31(2):249–59.CrossRefPubMedGoogle Scholar
  41. 41.
    Penninx BWJH, Kriegsman DMW, van Eijk JTM, Boeke AJP, Deeg DJH. Differential effect of social support on the course of chronic disease: a criteria-based literature study. Fam Syst Health. 1996;14(2):223–44.CrossRefGoogle Scholar
  42. 42.
    Chlebowy DO, Hood S, LaJoie AS. Facilitators and barriers to self-management of type 2 diabetes among urban African American adults: focus group findings. Diabetes Educ. 2010;36(6):897–905.CrossRefPubMedGoogle Scholar
  43. 43.
    Thorneloe RJ, Bundy C, Griffiths CE, Ashcroft DM, Cordingley L. Adherence to medication in patients with psoriasis: a systematic literature review. Br J Dermatol. 2013;168(1):20–31.CrossRefPubMedGoogle Scholar
  44. 44.
    Eissing L, Radtke MA, Zander N, Augustin M. Barriers to guideline-compliant psoriasis care: analyses and concepts. J Eur Acad Dermatol Venereol. 2016;30(4):569–75.CrossRefPubMedGoogle Scholar
  45. 45.
    Rubin DT, Mittal M, Davis M, Johnson S, Chao J, Skup M. Impact of a patient support program on patient adherence to adalimumab and direct medical costs in Crohn’s disease, ulcerative colitis, rheumatoid arthritis, psoriasis, psoriatic arthritis, and ankylosing spondylitis. J Manag Care Spec Pharm. 2017;23(8):859–67.PubMedGoogle Scholar
  46. 46.
    Miller WR, Rollnick S. Motivational interviewing: helping people change: New York: Guilford Press; 2012.Google Scholar
  47. 47.
    Zomahoun HTV, Guenette L, Gregoire JP, Lauzier S, Lawani AM, Ferdynus C, et al. Effectiveness of motivational interviewing interventions on medication adherence in adults with chronic diseases: a systematic review and meta-analysis. Int J Epidemiol. 2017;46(2):589–602.PubMedGoogle Scholar
  48. 48.
    Palacio A, Garay D, Langer B, Taylor J, Wood BA, Tamariz L. Motivational interviewing improves medication adherence: a systematic review and meta-analysis. J Gen Intern Med. 2016;31(8):929–40.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Teeter BS, Kavookjian J. Telephone-based motivational interviewing for medication adherence: a systematic review. Transl Behav Med. 2014;4(4):372–81.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Chisholm A, Nelson PA, Pearce CJ, Littlewood AJ, Kane K, Henry AL, et al. Motivational interviewing-based training enhances clinicians’ skills and knowledge in psoriasis: findings from the Pso Well® study. Br J Dermatol. 2017;176(3):677–86.CrossRefPubMedGoogle Scholar
  51. 51.
    Larsen MH, Krogstad AL, Aas E, Moum T, Wahl AK. A telephone-based motivational interviewing intervention has positive effects on psoriasis severity and self-management: a randomized controlled trial. Br J Dermatol. 2014;171(6):1458–69.CrossRefPubMedGoogle Scholar
  52. 52.
    Lerner JS, Tetlock PE. Accounting for the effects of accountability. Psychol Bull. 1999;125(2):255–75.CrossRefPubMedGoogle Scholar
  53. 53.
    Yentzer BA, Wood AA, Sagransky MJ, O'Neill JL, Clark AR, Williams LL, et al. An internet-based survey and improvement of acne treatment outcomes. Arch Dermatol. 2011;147(10):1223–4.CrossRefPubMedGoogle Scholar
  54. 54.
    Davis SA, Lin HC, Yu CH, Balkrishnan R, Feldman SR. Underuse of early follow-up visits: a missed opportunity to improve patients’ adherence. J Drugs Dermatol. 2014;13(7):833–6.PubMedGoogle Scholar
  55. 55.
    Laffer MS, Feldman SR. Improving medication adherence through technology: analyzing the managing meds video challenge. Skin Res Technol. 2014;20(1):62–6.CrossRefPubMedGoogle Scholar
  56. 56.
    Carroll CL, Feldman SR, Camacho FT, Manuel JC, Balkrishnan R. Adherence to topical therapy decreases during the course of an 8-week psoriasis clinical trial: commonly used methods of measuring adherence to topical therapy overestimate actual use. J Am Acad Dermatol. 2004;51(2):212–6.CrossRefPubMedGoogle Scholar
  57. 57.
    Shah A, Yentzer BA, Feldman SR. Timing of return office visit affects adherence to topical treatment in patients with atopic dermatitis: an analysis of 5 studies. Cutis. 2013;91(2):105–7.PubMedGoogle Scholar
  58. 58.
    Sagransky MJ, Yentzer BA, Williams LL, Clark AR, Taylor SL, Feldman SR. A randomized controlled pilot study of the effects of an extra office visit on adherence and outcomes in atopic dermatitis. Arch Dermatol (United States). 2010;146:1428–30.CrossRefGoogle Scholar
  59. 59.
    Feldman SR, Camacho FT, Krejci-Manwaring J, Carroll CL, Balkrishnan R. Adherence to topical therapy increases around the time of office visits. J Am Acad Dermatol. 2007;57(1):81–3.CrossRefPubMedGoogle Scholar
  60. 60.
    Yentzer BA, Gosnell AL, Clark AR, Pearce DJ, Balkrishnan R, Camacho FT, et al. A randomized controlled pilot study of strategies to increase adherence in teenagers with acne vulgaris. J Am Acad Dermatol. 2011;64(4):793–5.CrossRefPubMedGoogle Scholar
  61. 61.
    Sabate E, Sabaté E, Organisation mondiale de la s, World Health O, Unaids. Adherence to long-term therapies: evidence for action. New York: World Health Organization; 2003.Google Scholar
  62. 62.
    Zhang L, Yang H, Wang Y, Chen Y, Zhou H, Shen Z. Self-medication of psoriasis in southwestern China. Dermatology (Basel, Switzerland). 2014;228(4):368–74.CrossRefGoogle Scholar
  63. 63.
    Richards HL, Fortune DG, Griffiths CE. Adherence to treatment in patients with psoriasis. J Eur Acad Dermatol Venereol. 2006;20(4):370–9.CrossRefPubMedGoogle Scholar
  64. 64.
    Fenerty SD, West C, Davis SA, Kaplan SG, Feldman SR. The effect of reminder systems on patients’ adherence to treatment. Patient Prefer Adherence. 2012;6:127–35.Google Scholar
  65. 65.
    Yelamos O, Ros S, Puig L. Improving patient outcomes in psoriasis: strategies to ensure treatment adherence. Psoriasis (Auckland, NZ). 2015;5:109–15.Google Scholar
  66. 66.
    Feldman SR, Vrijens B, Gieler U, Piaserico S, Puig L, van de Kerkhof P. Treatment adherence intervention studies in dermatology and guidance on how to support adherence. Am J Clin Dermatol. 2017;18(2):253–71.CrossRefPubMedGoogle Scholar
  67. 67.
    Horwitz RI, Horwitz SM. Adherence to treatment and health outcomes. Arch Intern Med. 1993;153(16):1863–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Monica Shah
    • 1
  • Felicia Tai
    • 1
  • Abigail Cline
    • 2
  • Adrian Pona
    • 2
    Email author
  • E. J. Masicampo
    • 3
  • Steven R. Feldman
    • 4
  1. 1.Faculty of MedicineUniversity of TorontoTorontoCanada
  2. 2.Department of DermatologyWake Forest School of MedicineWinston-SalemUSA
  3. 3.Department of PsychologyWake Forest UniversityWinston-SalemUSA
  4. 4.Departments of Dermatology, Pathology and Social Sciences & Health PolicyWake Forest School of MedicineWinston-SalemUSA

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