Adherence intervention Research: The Need for a Multilevel Approach
W. Stewart Agras
Stanford University School of Medicine
This chapter serves as an introduction to compliance intervention research in pediatric populations, first discussing some of the problems facing the field, and then presenting an overview of the compliance intervention strategies used in the Coronary Primary Prevention Trial (CPPT), as a clinical example of a multilevel compliance intervention.
One of the first questions facing the researcher, or indeed the clinician, in addressing a compliance problem is at whom should the intervention be aimed? The obvious answer is the patient with the problem. On reflection this answer is, however, rather facile. It is evident, for example, in a pediatric population that the parent must also be the intervention target and is the only target in the case of the infant or very young child. Parental behavior must be changed to affect compliance in the infant or young child. Taking an even broader view, the health care system and the economy of the country also affect compliance in the individual patient and in turn are affected by poor compliance. For example, if a child does not receive adequate treatment by virtue of poor compliance and hence develops a chronic condition that may lead to more than average ill health, the health care system will have to absorb higher treatment costs, an employer may eventually have to pay larger insurance premiums and may also have to absorb the costs of absenteeism due to ill health.
There are, then, a number of possible organizational levels for compliance intervention research. These include: the patient, the patient's family, the worksite, the community, and the national economy on the one hand; the health care worker, the treatment team, the immediate clinical environment, and the larger institutional environment on the other. The vast majority of compliance intervention research has focused on the patient, and to a lesser extent, on the patient's