Commentary: Empirical Support for Common Sense Practices: A Commentary on Graves and Colleagues' Meta-analysis of Efficacy of Adherence Interventions

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Graves, Roberts, Rapoff, and Boyer (2010) recently reported data from a meta-analytic review of the efficacy of adherence interventions for chronically ill children. This timely article highlighted the importance of considering patient characteristics when creating an intervention, and suggested that clinicians will likely need to continue and improve in adapting interventions to meet the needs of each participant (p. 377). It should be noted, however, that the importance placed upon identifying patient characteristics that may affect the intervention is evidenced more in encouragements and recommendations than in reported findings. There is a paucity of literature related to the relationship between specific patient characteristics and affective adherence interventions in pediatric chronic illness. To add to the complexity, it is not only the pediatric patient’s particular characteristics or demographic information that must be considered, but also that of family members, as well, as parents/caregivers play a pivotal role in their child’s adherence to medication. As an example, in the present review ethnicity was only reported in 23% of the studies included in the meta-analysis, yet research indicates that medication adherence is worse among African Americans and Mexican Americans than Caucasians (Lanouette, Folsom, Sciolla, & Jeste, 2009; Leslie et al., 2006; Opolka, Rascati, Brown, & Gibson, 2003; Sleath et al., 2010;). Since most studies that examine the influence of race/ethnicity on medication adherence focus on elderly populations and adherence to psychotropic medication, more research that examines adherence to medication for chronic physical illness among pediatric populations is clearly needed. Some researchers have advocated for the use of a ‘‘difference model’’ in order to identify factors associated with adherence that are culture specific (Oyemade & Rosser, 1980). By separately examining factors in the behavior of groups that differ culturally, group differences are seen as important and are not interpreted as indicating deficiencies or deficits in the lower performing group(s) (Tucker et al., 2002). That recording the ethnicity of a participant is not standardized practice across research studies is surprising; such consistency would seem to enable more conclusions to be drawn regarding treatment effectiveness for particular ethnic groups, which is also noted by Graves et al. (p. 377). Medication adherence interventions typically consist of behavioral, education, organizational, or a combination of methods, but the literature does not indicate which type of intervention is likely to be most effective with Asian, Latino, or African-American patients. Failing to use ethnicity and/or culture as albeit imperfect proxies to identifying and understanding characteristics of the patient and his/ her family means that healthcare providers miss a great opportunity to uncover information that could be very useful to identifying potential difficulties with medication adherence. For example, parents of many children learned English as a second language, and they may be more likely to read the educational information presented to them if it is written at a less-advanced reading level or in their native language. This population might also particularly benefit from organizational interventions that focus on improving communication with healthcare providers. Different ethnicities and cultures interpret children’s behaviors in multiple ways, and these idiosyncrasies need to be addressed when involving parents in a behaviorally focused adherence program. Also, while it might seem completely sensible to alter a child’s environment in order to increase their medication adherence, simply encouraging parents to do this or giving them a list of changes to make in the home does not account for or consider whether these changes are feasible,