Table 1.

Summary of Assessment Methods for Adherence to Pediatric Regimens

Objective Methods
Bioassays
Advantages Can be used with blood, urine, or saliva Measures medication consumption (e.g., antiepileptic drugs) or therapeutic outcomes of treatment (e.g., hemoglobin A1c with diabetes, viral load suppression with HIV) Can be part of routine clinical care (especially if reimbursed)
Disadvantages Not available for some medications or relevant to particular regimen components (e.g., airway clearance with cystic fibrosis) Results may be affected by dose, timing, pharmacokinetics, and drug metabolism factors May not be sensitive enough to detect occasional (minor) non-adherence Does not provide information (e.g., patterns of non-adherence) that could inform treatment Has potential to be manipulated by patient (e.g., by dosing before appointment)
Electronic Monitoring
Advantages Has potential to measure a variety of adherence behaviors such as timing of dose/check (e.g., glucose), technique (e.g., with inhalers), which provides insight into medication taking patterns for treatment planning purposes
Disadvantages Usually does not measure actual consumption of medication (e.g., MEMSTM cap measures opening a bottle) Complex to use (e.g., training required for software & equipment) Is costly (e.g., devices, equipment, web access fees) and most are not reimbursed by insurance (except for blood glucose monitors & insulin pumps for diabetes) Is not compatible with all medications (e.g., large pills) and does not apply to certain regimen components (e.g., dietary adherence) Associated with technological issues such as battery failure and malfunction (e.g., inhaler monitor registering use as the result of being shuffled within a child’s backpack) May not be acceptable to patients and families
Pharmacy Refill Data
Advantages Generally inexpensive (though some pharmacies may charge fees for records) Fairly accurate (correlates significantly with electronic monitoring data)
Disadvantages Does not measure consumption Need to consider possibility of patients using other pharmacies, stockpiling medications, or using family members’ medication Logistics (e.g., staff time, privacy regulations) to obtain records may be difficult Will not be applicable if patient’s medications are refilled automatically
Pill count/Canister Weight
Advantages Inexpensive Fairly accurate (correlates significantly with electronic monitoring data)
Disadvantages Patients may forget to bring their medication to clinic or miss their appointment Has potential to be manipulated by patient (e.g., dump medication prior to clinic appointment) Does not confirm that medication was ingested Can be cumbersome for staff to collect & calculate
Subjective Methods
Interviews
Advantages Can obtain information on a variety of regimen components, not just medication use Has potential to provide information on related issues, such as family routines, that could be useful for treatment planning Some can be administered over the telephone, as well as in clinic
Disadvantages Relies on self-report; subject to recall bias Accuracy depends on the psychometric properties and structure of the interview
Diary/Self-Monitoring
Advantages Reduces demands on memory Inexpensive Flexible; can be devised to monitor a range of variables (e.g., timing, duration) in relation to a variety of adherence components (e.g., diet, medication use, physical exercise)
Disadvantages Relies on self-report; has potential to be fabricated by patient, perhaps due to social desirability Requires “adherence” to recording information, when adherence is a general concern
Questionnaires
Advantages Inexpensive Convenient & relatively unobtrusive; can be administered during wait time & reviewed by clinic staff during appointment
Disadvantages Relies on self-report; subject to bias & social desirability May mask variability of adherence across regimen components if assessed globally

Sources: Garfield et al., 2011; Haynes et al., 2002; Hommel et al., 2008; Hommel, Mackner, Denson, & Crandall, 2013; Marhefka et al., 2006; Quittner et al., 2008