Patient Related Factors

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This category of risk factors has been most extensively studied both in the literature on rheumatic disorders as well as in chronic disease populations in general, clearly indicating a bias as the patient is being seen as the defaulter.

Knowledge about the treatment and the illness is essential for patient's adherence, but information alone is not enough to promote the behavioral changes required as part of the management of the disease (1). Even when patients are given information, they often misunderstand what the doctor says and fail to recall much of the information they are given. Moreover, patients at a lower level of cognitive functioning or with lower intellectual capacities may have difficulties understanding and executing the complex therapeutic regimen. Many patients also stated that forgetfulness was one of the most common reasons for nonadherence (4,24), together with interference of pharmacological and non-pharmacological treatment with the hectic daily life schedules of teenagers.

Adolescents with a chronic disease are often hindered in their striving towards normality and autonomy, which may lead to depression, behavioral disturbances, low self-esteem, or social adjustment difficulties (24,54-56). Patients with recent onset chronic illness must renegotiate their self-identities as formerly well persons. Denial of disease may reflect patients' resistance to accept their illness and medications act as a reminder that they are not "normal," which may consequently result in poor adherence with proposed treatment (54). Myths about arthritis that permeate the public perception may also indirectly contribute to poor adherence. Because arthritis is generally viewed as an inevitable consequence of old age, adolescents can meet disbelief from their environment, which may provoke additional psychological distress.

Another powerful predictor of poor adherence is self-efficacy. Self-efficacy refers to one's confidence in performing a particular behavior (57,58). In a large study by Kyngas and colleagues, motivation, energy and will power, and feeling arthritis as a threat to their social well being were independent predictors of adherence (53,59).

Patients and their families also have their own ideas about the causes of rheumatic disease, the flare-ups of disease activities, the seriousness of disease, the efficacy of treatment, and the consequences of poor adherence (51,60). Those beliefs are sometimes based on misassumptions or ideas offered by relatives, friends or the lay press, which do not always correspond with the reality (34,51,60-62). It is assumed that health beliefs (i.e., treatment perceptions and illness representations) more strongly influence medication adherence than socio-demographic of clinical factors (63). The self-regulatory theory proposed that patients make the decision to adhere on the basis of a cost-benefit analysis, considering whether their beliefs about the necessity of treatment (e.g., medication taking, exercising) for maintaining health outweigh their concerns about its potential adverse effects (e.g., side effects, muscle pain, having less time for friends) (61,63). Such beliefs are thought to influence families' use of complementary and alternative medicines who may perceive prescribed treatment as "unnatural", fear side effects of conventional medications, or believe them to be inefficacious (64). Feldman et al. (28) suggests that the use of complementary and alternative therapies does not necessarily predict poor adherence with conventional treatments, but may indicate that the adolescent is having problems managing their disease. Questioning the use of complementary and alternative medicines should, therefore, be part of routine clinical assessment. Not only does this enable discussion about health beliefs regarding treatment, but may also open up a discourse regarding the potential side-effects of complementary and alternative medicines and their interactions with medical therapy.

Another study regarding health beliefs on medication adherence in adult patients showed that areas of concern were the potential long-term adverse effect of their medications and the fear of becoming dependent upon medication (65). This study found that concerns of the adherent group were significantly lower than those of the nonadherent group (65). Perception of necessity was not significantly different between both groups. This observation underscores that we should perhaps concentrate more on reassuring patients about the safety of the treatments we prescribe, than on convincing them of the benefits of treatment (65).

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