The World Health Organization (2003) has endorsed the following definition of adherence: "the extent to which a person's behavior—taking medication, following a diet, and/or executing lifestyle changes—corresponds with agreed recommendations from a health care provider." This definition highlights three critical points: 1) that patient agreement to the recommendation is essential, 2) that adherence is a behavior, and 3) that the degree of adherence is important.

The definition posits that the treatment recommendations have to be agreed upon by the patient, the parent, or both. In some cases, the child's agreement may not be required, and seeking agreement only from the caretaker may be adequate. Accordingly, without such agreement, the patient's behavior should not be described as nonadherence but rather as a disagreement with medical recommendations. Implicit is the notion that the patient and/or caretaker receives accurate and complete treatment information. If this does not occur, then deviations from the desired treatment should similarly not be attributed to a lack of adherence. Another important aspect of the definition is that nonadherence is considered a behavior and should not be defined as a mental health disorder. Finally, an emphasis is placed on assessing not only whether the patient follows a treatment recommendation but also to what extent it is followed. In certain situations, a patient might still be considered to be sufficiently adherent even if recommendations are not followed fully. The point at which nonadherence becomes clinically significant (i.e., when the degree of nonadherence results in the patient being unable to achieve the anticipated improvement in medical outcome) has been termed the adherence threshold.

The adherence threshold is related to patient and disease characteristics. Researchers frequently either ignore this issue or assume an adherence threshold that may or may not be valid (e.g., "the likelihood that a patient has taken the medication within 2 hours of the prescribed dose," or "adherence to 70%

or more of the regimen was considered adequate"). The lack of a defined adherence threshold or use of an arbitrary definition makes it difficult to interpret the results or compare studies. Furthermore, without data concerning the precise threshold for the degree of nonadherence that is clinically significant, providers have difficulty identifying the "highest risk" nonadherent patients. Although an effort is currently under way to better determine adherence thresholds in specific populations (Stuber et al. 2008), further work is needed in this area.

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