Risk Factors

Risk factors for treatment nonadherence include a myriad of issues and barriers related to patients and their environments. Several attempts have been made to model risk categories as a part of a single conceptual framework (e.g., the health-belief and self-efficacy models) (Chao et al. 2005; DiMatteo et al. 2007; Drotar 2000; Graham et al. 2007; Harka-paa et al. 1991). Although these models have merit, a biopsychosocial model is particularly helpful in understanding and delineating specific nonadherence risk factors (Novack et al. 2007) (see Table 13-1).

Research on nonadherence risk factors has been cross-sectional and, as such, does not allow a determination of potential causal relationships. In addition, the influence of outcome mediators or moderators has not been well studied. Meta-analyses of existing studies have been used to stratify risk factors and treatment effects (DiMatteo et al. 2000, 2002; Fischbach et al. 2004; Iskedjian et al. 2002; Kothawala et al. 2007; Mills et al. 2006; Nieuwkerk and Oort 2005; Nose et al. 2003; Peterson et al. 2003a, 2003b; Simpson et al. 2006; Sofi et al. 2008; Takiya et al. 2004; Voils et al. 2007; Wu and Roberts 2008). Problematic issues in these meta-analy-ses are that the assessment methods vary across studies, often do not correlate with each other, and may not even examine the same behavior (Kikkert et al. 2008). Attempts to lump different studies together using the same analytic strategy may lead to results that cannot be replicated and do not truly capture the clinical realities.

These problems may explain the significant discrepancy in the results reported in different meta-analyses. For example, one meta-analysis of 17 studies of pediatric transplant recipients found that psychosocial factors were significantly related to nonad-herence (Kahana et al. 2008), and the authors concluded that psychosocial factors are the most important risk factors in this field. By contrast, another meta-analysis of 147 studies of adult transplant recipients found little evidence for a relationship between psychosocial factors and nonadherence, and these authors' recommendation was that psychosocial factors should not be the sole focus of research and intervention (Dew et al. 2007). Until the measurement of adherence becomes more uniform, results of such analyses should be interpreted with caution. Although one can reasonably assume that psychosocial factors do play a role in determining pediatric nonadherence, one must keep in mind the potential influence of provider-related and health system factors.

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