Health care setting and health care provider-related factors receive too little attention in the literature, yet is recognized by the World Health Organization to be a key determinant in understanding nonadherence (70). This again illustrates the bias in the literature that health care workers prefer to blame the patient for his/her nonadherent behavior, and are reluctant to see themselves as potential contributors of nonadherence.
The amount of direct communication between a doctor and child has been shown to be positively associated with adherence (71). The need for health-related information and effective communication with doctors and other health care providers are major concerns for adolescents (72). Research has shown the relatively passive involvement of young people during consultations, with parent-doctor interactions dominating, and information-giving being directed at the parent as opposed to the young person (73,74). When patients are encouraged to actively participate in decisions concerning their care, they may be more committed to those decisions and ultimately achieve higher levels of adherence (59). In addition, patient-centered care as opposed to condition-focused care will also have a beneficial impact on adherence (61,75). Key features of good doctor-patient interaction are shared goal setting, written management plans and regular follow-up (59,75), i.e. all characteristics that perfectly fit into the concept of "concordance."
Fewer clinic visits and shorter duration of specialist care have also been associated with poor adherence (23). However, support from the health care team may be valuable sources to empower adherence. In a study of Kyngas et al. (59), the most powerful predictor was support from nurses, with adolescents experiencing support from nurses being 7.28-fold more likely to be adherent compared to teenagers not feeling supported by nurses. Support received from physicians, parents and peers was also extremely important (i.e., odds ratios were 3.42, 2.69, and 2.11 respectively).
The fact that an acute illness model prevails instead of a chronic illness management model could also be seen as a system-related factor contributing to nonadherence. Chronic illness management models that put the patient in the centre of care, provide continuity, address psychosocial, and behavioral issues as much as medical issues, and promote active participation of an informed patient have been shown to enhance the clinical outcomes in a number of chronically ill populations (70,76,77).
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