Non-adherent Individuals Research Articles

Antiretroviral therapy adherence measurement in non-clinical settings in South India

Optimal adherence to antiretroviral therapy (ART) is key to viral suppression, but may be impeded by psychosocial consequences of HIV-infection such as stigma and depression. Measures of adherence in India have been examined in clinic populations, but little is known about the performance of these measures outside clinical settings. We conducted a cross-sectional study of 151 Tamil-speaking people living with HIV/AIDS (PLHA) in India recruited through HIV support networks and compared single item measures from the Adult AIDS Clinical Trial Group (AACTG) scale, a visual analog scale (VAS), and a question on timing of last missed dose. Depression was measured using the Major Depression Inventory (MDI) and HIV-related stigma was measured using an adaptation of the Berger Stigma Scale. Mean age was 35.6 years (SD ± 5.9); 55.6% were male; mean MDI score was 11.9 (SD ± 9.1); and mean stigma score was 67.3 (SD ± 12.0). Self-reported perfect adherence (no missed doses) was 93.3% using the AACTG item, 87.1% using last missed dose, and 83.8% using the VAS. The measures had moderate agreement with each other (kappa 0.45–0.57). Depression was associated with lower adherence irrespective of adherence measure used, and remained significantly associated in multivariable analyses adjusting for age and marital status. Stigma was not associated with adherence irrespective of the measure used. The VAS captured the greatest number of potentially non-adherent individuals and may be useful for identifying PLHA in need of adherence support. Given the consistent and strong association between poorer adherence and depression, programs that jointly address adherence and mental health for PLHA in India may be more effective than programs targeting only one.

Adherence to treatment in a Western European paediatric population with haemophilia: reliability and validity of the VERITAS-Pro scale.

Treatment adherence in haemophilia is strongly associated with quality of life and the cost-benefit of treatment. Therefore, it is important to quantify and monitor it. This study aimed to validate a translation of the VERITAS-Pro cross-culturally and analyse treatment adherence in a Dutch population of paediatric haemophilia patients. Children aged 1-18years with haemophilia were included from three Haemophilia Treatment Centres, on prophylactic clotting factor replacement therapy for more than 1 year. Parents and adolescents were analysed separately. The adherence scale for prophylactic therapy (VERITAS-Pro) was translated according to international guidelines. This instrument contains a total of six subscales ('Time', 'Dose', 'Plan', 'Remember', 'Skip' and 'Communicate') each with four items. Lower scores reflect higher adherence. Overall response rate was 85%, leading to a study population of 60 children. Mean age was 10years (SD 4.1). Internal consistency reliability: Mean Cronbach's alphas were adequate (>0.70) for total score and the subscales 'Skip' and 'Communicate'. Item-own subscale correlations were stronger than most item-other subscale correlations. Convergent validity: Total scores were higher for non-adherent participants compared with adherent participants according to patient infusion logs (n=48; P<0.05). Test-retest correlations: Significant for all scales except 'Dose' (n=58; P<0.01). This study demonstrates applicability of VERITAS-Pro outside the United States, as total score and most subscales effectively quantified treatment adherence in a Dutch paediatric population on prophylactic therapy. Non-adherent respondents' total scores were significantly higher, demonstrating the ability of VERITAS-Pro to identify non-adherent individuals.

Patient choice as a driver of medication-switching in non-adherent individuals with bipolar disorder.

ObjectivePsychotropic-related weight gain is a common concern among patients with bipolar disorder (BD). This concern affects satisfaction with treatment and may lead to non-adherence and relapse. This was a 12-week, uncontrolled prospective trial of patient-choice–facilitated ziprasidone switching among non-adherent BD patients with weight concerns. This study was conducted from January 2011 to July 2012.MethodPatients were asked to identify the “offending” BD medication which they believed was causing weight problems, and this agent was replaced with ziprasidone. The primary outcome was change in adherence as measured with the Tablets Routine Questionnaire (TRQ). Secondary outcomes included medication attitudes, BD symptoms, global psychopathology, social functioning, and quality of life.ResultsThe most common agents causing weight concerns were quetiapine (N=7, 23%), aripiprazole (N=4, 13%), olanzapine, lithium, and divalproex (all N=3, 10%). Adherence improved from a baseline of missing 48.6% of prescribed BD medication in the past week (44.9% in the past month) to missing 25.3% (P=0.002) of prescribed BD medication in the past week (P<0.001, in the past month) at endpoint. Medication attitudes, symptoms, functioning, and quality of life improved but there were no differences in body weight.ConclusionWhile findings must be tempered by methodological limitations such as small sample and uncontrolled design, patient-facilitated medication-switching appeared to improve adherence and BD outcomes in these non-adherent individuals. Additional studies involving patient-facilitated medication-switching and shared decision-making in BD are needed.

Decision support model applied to the recognition of non-adherent individuals to antihypertensive therapy

Decision support model applied to the recognition of non-adherent individuals to antihypertensive therapy

Evaluation of Primary Nonadherence to Oral Bisphosphonate Therapy

Evaluation of Primary Nonadherence to Oral Bisphosphonate Therapy

A Mobile Colonoscopic Unit for Lynch Syndrome: Trends in Surveillance Uptake and Patient Experiences of Screening in a Developing Country

The Genetic and Endoscopic Surveillance Clinic is an annual outreach service offering accessible colonoscopic surveillance to known families with Lynch syndrome living in remote areas of the Western and Northern Cape Province of South Africa. Unfortunately attendance at this outreach clinic has been declining over several years and fewer than a quarter of participants, attending for surveillance, have been adherent with all their recommended screening appointments. Concerns exist for non-adherent individuals as screening can prevent colorectal cancer by removing the precancerous lesion or enabling the treatment of a malignancy at an early stage. This study explored the experience of surveillance from both the non-adherers' and adherers' perspectives and identified unique factors affecting attendance at the outreach clinic. Rates of compliance are calculated for 191 mutation-positive cases of Lynch syndrome, using strict attendance criteria, and compared to figures obtained from self-reported attendance. Non-compliance was under-reported and compliance was exaggerated when basing data on self-reported adherence to recommendations. Specific characteristics of the outreach clinic affecting compliance are identified and recommendations are made to facilitate improvements to the service. These improvements can result in increased compliance with screening regimens and ultimately reduce cancer-related mortality.

Six‐month outcomes of customized adherence enhancement (CAE) therapy in bipolar disorder

There are few psychosocial interventions specifically focused on improved treatment adherence in people with bipolar disorder (BD). Customized adherence enhancement (CAE) is a needs-based, manualized approach intended to improve medication adherence in individuals with BD. This was a six-month prospective trial of a CAE among 43 medication non-adherent individuals with BD who were receiving treatment in a community mental health clinic (CMHC). CAE was flexibly administered in modules applied as indicated by an initial adherence vulnerabilities screening. Screening identified reasons for non-adherence and modules were then administered using pre-set criteria. CAE effects were evaluated at six-week, three-month, and six-month follow-up. The six-month follow-up was our primary time point of interest. The primary outcome was change from baseline in adherence using the Tablets Routine Questionnaire (TRQ) and pill counts. Secondary outcomes included change from baseline in BD symptoms [Hamilton Depression Rating Scale (HAM-D), Young Mania Rating Scale (YMRS), and Brief Psychiatric Rating Scale (BPRS)]. Subjects completed 86% of scheduled sessions, with only two individuals (5%) not participating in any sessions. The number of dropouts at six months was 12 (28%). Mean baseline non-adherence by TRQ was 48% [standard error (SE) 4.8%] missed tablets within the previous week and 51% (4.1%) missed tablets within the previous month. At six-month follow-up, mean TRQ non-adherence improved to 25% (6.8%) missed tablets for the previous week (p = 0.002) and 21% (5.5%) for the previous month (p < 0.001). Symptoms improved, with a change in the baseline mean (SE) BPRS of 43.6 (1.8) versus an endpoint of 36.1 (2.3) (p = 0.001), and baseline mean (SE) HAM-D of 17.8 (1.1) versus an endpoint of 15.3 (1.6) (p = 0.044). CAE was associated with improvements in adherence, symptoms, and functional status. Controlled trials are needed to confirm these preliminary findings.

Adherencia al programa poblacional de detección precoz de cáncer colorrectal en Cataluña, 2000-2008

ObjectiveTo analyze correlates of adherence to colorectal cancer screening with biennial fecal occult blood testing in asymptomatic individuals aged 50 to 69 years. MethodsA cross-sectional telephone survey was conducted among people (n = 1,193) invited to participate in at least two successive rounds of a population-based colorectal cancer screening program in L’Hospitalet de Llobregat (Barcelona, Spain). Subjects were classified according to their adherence to colorectal cancer screening guidelines (non-adherent, irregular adherent and totally adherent). Independent variables were sociodemographic variables, self-perceived health, attitudes and beliefs regarding colorectal cancer and preventive activities. Binary and politomous logistic regression models were performed. ResultsOf the individuals invited to participate in the screening program, 14.4% were adherent to screening recommendations and 18.4% were occasionally adherent. Significant differences were found in beliefs and attitudes regarding colorectal cancer and its early detection among adherent and non-adherent individuals. Sharing the decision to participate in screening with a family member increased adherence by nine- and tweve-fold. A positive perception of the screening process was a facilitator to adherence. ConclusionsAttitudes and beliefs regarding colorectal cancer and its early detection, as well as familial support, are associated with initial participation in colorectal cancer screening but do not affect the persistence of preventive behavior over time.

Predictors of Medication Adherence in Patients with Rheumatoid Arthritis.

Medication adherence is a significant problem in patients with rheumatoid arthritis (RA), a prevalent autoimmune disease. Due to the equivocal results reported in the research, consistent predictors of medication adherence in patients with RA are undetermined. A cross-sectional descriptive, predictive study of 108 patients with RA was used to: 1) describe self-reported medication adherence to disease modifying anti-rheumatic drugs (DMARDs); 2) compare demographic (age, residence, marital status, employment status, years of education, and ethnicity) and clinical (duration of disease and number of medications) factors of adherent and non-adherent individuals; and 3) determine the predictive power of demographic and clinical factors for DMARD adherence using various cut-points (research-based, mean, and median) on a validated, self-report scale measuring medication adherence. Independent samples t-tests, Chi square analyses, and logistic regression modeling were used to analyze these data. Approximately 90% of the individuals with RA reported adherence with their prescribed DMARD prescriptions. The only demographic and clinical difference between the adherent and non-adherent group was ethnicity (p=0.04); nonwhite individuals reported significantly less adherence with their prescribed DMARDs when compared to white individuals. Logistic regression models identified ethnicity (OR= 3.34-10.1; p< 0.05) and the number of medications taken (OR=1.7; p< 0.05) as predictors of medication non-adherence. These data provide evidence that ethnicity and taking an increased number of prescribed medications are independent predictors of medication adherence in patients with RA. These findings confirm the presence of a health disparity and an area where further research is needed to optimize patient outcomes.

Risk management in HIV/AIDS: ethical and economic issues associated with restricting HAART access only to adherent patients

Like many other developing nations, South Africa faces the challenge of mobilising resources in response to the HIV pandemic. There is a large budget gap between the ideal and the actual amount of funding needed to achieve universal access to highly active antiretroviral therapy (HAART). In addition to financial demands, new burdens are being placed on HAART programmes with the emergence of HIV drug resistance (HIVDR). Thus, a major threat to successful HAART rollout is HIVDR due to non-adherence to HAART. The use of HAART as a primary and secondary HIV-prevention strategy could be ineffective in situations characterised by high rates of non-adherence. In this context, the research looked at issues related to adherence and non-adherence to HAART from the perspective of the provider. Using the software TreeAge Pro 2009, we developed a Markov model to project economic outcomes for a hypothetical cohort of HIV/AIDS patients on HAART. The model compared two scenarios: adherence and non-adherence to HAART. Input data for the model was obtained from existing literature on HAART uptake in South Africa. Moral arguments were analysed and managed through moral reasoning and critical thinking. Discounted lifetime costs for adherent and non-adherent HAART patients in South Africa were estimated at US$9 771 and US$14 762, respectively. The model showed the loss of 4.55 quality-adjusted life years (QALYs) for non-adherent patients, which could be otherwise gained through improved adherence. The incremental cost-effectiveness ratio (ICER) indicated that restricting HAART access only to adherent patients was the dominant strategy. We suggest that, although not a panacea, the withholding or withdrawal of treatment from non-adherent individuals as a precautionary intervention has economic and moral merit.

Improving the measurement of self-reported medication nonadherence: Response to Authors

Improving the measurement of self-reported medication nonadherence: Response to Authors

Taking Less Than Prescribed: Medication Nonadherence and Provider‐Patient Relationships in Lower‐Income, Rural Minority Adults With Hypertension

Control of hypertension remains poor, and lack of adherence to medication is considered a primary reason. Few studies have examined the reasons for medication nonadherence in African American, lower-income, rural adults receiving medications at no personal cost. Moreover, our understanding of how the provider-patient relationship influences adherence in this population is limited. In this study, the authors (1) examined reasons for taking less medication than prescribed and (2) examined the association between provider-patient variables and medication adherence. A total of 434 participants (94.8% African American) were included. The most frequently endorsed reasons for taking less medication than prescribed were not having blood pressure medicine when it was time to take a dose (36%), running out of medicine (35%), bothered by side effects (29%), and a change in one's daily routine (27%). Nonadherent individuals were significantly more likely to report discomfort with asking the health provider questions (74% vs 63%), were more likely to report that health care visits were stressful (25% vs 16%), and exhibited more depressive symptoms (58% vs 45%). Adherent patients had lower blood pressure (systolic: 133±15.8 mm Hg vs 138±17.6 mm Hg, P value=.002; diastolic: 80±9.8 mm Hg vs 83±11 mm Hg, P value=.003) than individuals who were less adherent. Clinicians providing care to rural, poor hypertensive patients should routinely assess self-management behaviors, logistical barriers, and emotional health. Creating clinical encounters that minimize the stressful nature of the visit and encourage patient question-asking behavior may also be important for the optimal management of hypertension.

Illness experience and reasons for nonadherence among individuals with bipolar disorder who are poorly adherent with medication

Aim Nonadherent individuals are the most likely to avoid participating in research studies, thus limiting potential opportunities to develop evidence-based approaches for adherence enhancement. This mixed-method analysis evaluated factors related to adherence among 20 poorly adherent community mental health clinic patients with bipolar disorder (BD). Methods Illness experience was evaluated with qualitative interview. Quantitative assessments measured symptoms (Hamilton Depression Rating Scale, Young Mania Rating Scale, Brief Psychiatric Rating Scale), adherence behavior, and treatment attitudes. Poor adherence was defined as missing 30% or more of medication. Results Minorities (80%), unmarried individuals (95%), and those with substance abuse (65%) predominated in this nonadherent group of patients with BD. Individuals were substantially depressed (mean Hamilton Depression Rating Scale, 19.2), had at least some manic symptoms (mean Young Mania Rating Scale, 13.6), and had moderate psychopathology (mean Brief Psychiatric Rating Scale, 41.2). Rates of missed medications were 41% to 43%. Forgetting to take medications was the top reason for nonadherence (55%), followed by side effects (20%). Disorganized home environments (30%), concern regarding having to take long-term medications (25%) or fear of side effects (25%), and insufficient information regarding BD (35%) were relatively common. Almost one third of patients had individuals in their core social network who specifically advised against medication. Access problems included difficulty paying for medications among more than half of patients. Interestingly, patients reported good relationships with their providers. Conclusions Forgetting to take medication and problems with side effects are primary drivers of nonadherence. Lack of medication routines, unsupportive social networks, insufficient illness knowledge, and treatment access problems may likewise affect overall adherence. Complementary quantitative and qualitative data collection can identify reasons for nonadherence and may inform specific clinical approaches to enhance adherence.

Training inpatient mental health staff how to enhance patient engagement with medications: Medication Alliance training and dissemination outcomes in a large US mental health hospital

The Medication Alliance training programme has previously been shown to be effective in enhancing clinician knowledge, attitudes and skills in regard to non-adherent individuals in a community-based psychiatric setting. The current study attempts to replicate these findings in an inpatient setting and assess the feasibility of dissemination using a train-the-trainer model. One hundred and thirteen staff from four wards at an inpatient psychiatric facility attended Medication Alliance training workshops over 3 days. Two wards comprised an expert trained group (n = 67); and the remaining two wards made up a novice trained group (n = 46). The novice trained group attended training 6 months after the expert group, and were trained by selected trainees from the expert group. Participants completed a package of questionnaires both before and after their training to determine if Medication Alliance resulted in any changes in knowledge, attitudes and skills. Paired t-tests showed significant improvements across both groups for knowledge, attitudes and one skill domain following training in Medication Alliance. There were no differences at baseline between groups and analysis of post-test scores yielded no significant difference between the groups in terms of training effect for knowledge, attitudes or skills. Medication Alliance can be successfully implemented in an inpatient setting, enhancing knowledge, attitudes and at least some skill domains of staff in dealing with non-adherent patients. The equivalence of results between the expert and novice trained training groups suggests that Medication Alliance may be more broadly disseminated using a cost-effective train-the-trainer model.

An Exploratory Study of Factors Influencing Glaucoma Treatment Adherence

To understand the factors that influence glaucoma treatment adherence with medication taking, prescription refills, and appointment keeping to develop an intervention for a specific population. In-depth interviews were conducted with 80 individuals diagnosed with open-angle glaucoma, glaucoma suspect, or ocular hypertension. Additional eligibility requirements were that all participants were: between the ages of 18 to 80; white or African American; spoke and understood English; and were taking daily doses of topical glaucoma treatments for at least the past year. Cross-tabulations and chi2 tests were conducted to compare adherent and nonadherent individuals, classified as such based on self-report and medical chart/pharmacy data. Compared with adherent participants, nonadherent participants were less likely to: believe their eye doctors spent sufficient time with them; ask their eye doctor if they had any questions; know of benefits to taking their glaucoma medication regularly; and have someone help them take their glaucoma medications or drive them to eye appointments. Conversely, compared with adherent individuals, nonadherent participants were more likely to have difficulty remembering to take their medications and to believe their glaucoma would affect their eye sight in the future. Nonadherent glaucoma patients struggle with a variety of issues related to consistent use of glaucoma medicine and routine eye care. Interventions are needed to address these modifiable factors related to glaucoma treatment adherence.

Sociodemographic and Clinical Characteristics Are Not Clinically Useful Predictors of Refill Adherence in Patients With Hypertension

Although many studies have identified patient characteristics or chronic diseases associated with medication adherence, the clinical utility of such predictors has rarely been assessed. We attempted to develop clinical prediction rules for adherence with antihypertensive medications in 2 healthcare delivery systems. We performed retrospective cohort studies of hypertension registries in an inner-city healthcare delivery system (n=17 176) and a health maintenance organization (n=94 297) in Denver, Colo. Adherence was defined by acquisition of 80% or more of antihypertensive medications. A multivariable model in the inner-city system found that adherent patients (36.3% of the total) were more likely than nonadherent patients to be older, white, married, and acculturated in US society, to have diabetes or cerebrovascular disease, not to abuse alcohol or controlled substances, and to be prescribed fewer than 3 antihypertensive medications. Although statistically significant, all multivariate odds ratios were 1.7 or less, and the model did not accurately discriminate adherent from nonadherent patients (C statistic=0.606). In the health maintenance organization, where 72.1% of patients were adherent, significant but weak associations existed between adherence and older age, white race, the lack of alcohol abuse, and fewer antihypertensive medications. The multivariate model again failed to accurately discriminate adherent from nonadherent individuals (C statistic=0.576). Although certain sociodemographic characteristics or clinical diagnoses are statistically associated with adherence to refills of antihypertensive medications, a combination of these characteristics is not sufficiently accurate to allow clinicians to predict whether their patients will be adherent with treatment.

The Combined Effect of Modern Highly Active Antiretroviral Therapy Regimens and Adherence on Mortality Over Time

To characterize the impact of longitudinal adherence on survival in drug-naive individuals starting currently recommended highly active antiretroviral therapy (HAART) regimens. Eligible study participants initiated HAART between January 2000 and November 2004 and were followed until November 2005 (N = 903). HAART regimens contained efavirenz, nevirapine, or ritonavir-boosted atazanavir or lopinavir. Marginal structural modeling was used to address our objective. The all-cause mortality was 11%. Individual adherence decreased significantly over time, with the mean adherence shifting from 79% within the first 6 months of starting HAART to 72% within the 24- to 30-month period (P value <0.01). Nonadherence over time (<95%) was strongly associated with higher risk of mortality (hazard ratio: 3.13; 95% confidence interval (CI): 1.95 to 5.05). Nonadherent (<95%) patients on nonnucleoside reverse transcriptase inhibitor (NNRTI)-based and boosted protease inhibitor-based regimens were, respectively, 3.61 times (95% CI: 2.15 to 6.06) and 3.25 times (95% CI: 1.63 to 6.49) more likely to die than adherent patients. Within the NNRTI-based regimens, nonadherent individuals on efavirenz were at a higher risk of mortality. Incomplete adherence to modern HAART over time was strongly associated with increased mortality, and patients on efavirenz-based NNRTI therapies were particularly at a higher risk if nonadherent. These results highlight the need to develop further strategies to help sustain high levels of adherence on a long-term basis.

Timing is everything: antiretroviral nonadherence is associated with impairment in time-based prospective memory.

Nonadherence to combination antiretroviral (ARV) therapies (cART) is highly prevalent and significantly increases the risk of adverse human immunodeficiency virus (HIV) disease outcomes. The current study evaluated the hypothesis that prospective memory-a dissociable aspect of episodic memory describing the ability to execute a future intention-plays an important role in successful cART adherence. Seventy-nine individuals with HIV infection who were prescribed at least one ARV medication underwent a comprehensive neuropsychological and neuromedical evaluation prior to completing a 1-month observation of their cART adherence as measured by electronic medication monitoring. Nonadherent individuals (n = 31) demonstrated significantly poorer prospective memory functioning as compared to adherent persons (n = 48), particularly on an index of time-based ProM (i.e., elevated loss of time errors). Deficits in time-based prospective memory were independently predictive of cART nonadherence, even after considering the possible influence of established predictors of adherence, such as general cognitive impairment (e.g., retrospective learning and memory) and psychiatric comorbidity (e.g., depression). These findings extend a nascent literature showing that impairment in time-based prospective memory significantly increases the risk of medication nonadherence and therefore may guide the development of novel strategies for intervention. (JINS, 2009, 15, 42-52.).

Barrier-focused intervention to increase colonoscopy attendance among nonadherent high-risk populations

To increase attendance for colonoscopy among nonadherent high-risk individuals for colorectal cancer (CRC) screening in China. During the first 12 mo without intervention, only 428 of the 2398 high-risk subjects attended a scheduled colonoscopy examination. The 1970 subjects who did not attend for CRC screening were enrolled in the present study. Prior barrier investigation was performed to ascertain the reasons for nonadherence. A barrier-focused intervention program was then established and implemented among eligible nonadherent subjects by telephone interviews and on-site consultations. The completion rates of colonoscopy during the first 12 mo without intervention and the second 12 mo with intervention were compared. Variations in the effect of the intervention on some high-risk factors and barrier characteristics were analyzed using logistic regression. 540 subjects who were not eligible were excluded from the study. The colonoscopy attendance rate was 23.04% (428/1858) during the first 12 mo without intervention, and 37.69% (539/1430) during the second 12 mo with intervention (P < 0.001). Logistic regression analysis showed that the intervention was more effective among subjects with only objective barriers (OR: 34.590, 95% CI: 23.204-51.563) or subjects with some specific high-risk characteristics: first-degree relatives diagnosed with CRC (OR: 1.778, 95% CI: 1.010-3.131), personal history of intestinal polyps (OR: 3.815, 95% CI: 1.994-7.300) and positive result for immunochemical fecal occult blood testing (OR: 2.718, 95% CI: 1.479-4.996). The barrier-focused telephone or on-site consultation intervention appears to be a feasible means to improve colonoscopy attendance among nonadherent high-risk subjects for CRC screening in China.

Prevalência da adesão ao tratamento anti-hipertensivo em hipertensos resistentes e validação de três métodos indiretos de avaliação da adesão

This study estimated adherence to anti-hypertensive medication using three indirect methods and their combinations in a cohort of patients with resistant hypertension in Rio de Janeiro, Brazil, 2005. The methods used were: self-reported adherence; physicians' adherence evaluation; and the Morisky-Green test (MGT) translated into Portuguese. The predictive validation was performed comparing office blood pressure and ambulatory blood pressure monitoring, measured on two different occasions, from patients classified as adherent or not. The means were compared using non-parametric tests. Two hundred patients were interviewed. Mean age was 63 years (SD = 10.3), and 73.5% were female. Adherence prevalence was 51% using MGT, 52% according to the physician, and 80.5% according to the patient. Adherent patients showed a reduction in both office blood pressure and ambulatory blood pressure, while non-adherent patients did not. The use of more than one method to evaluate adherence showed that non-adherent individuals according to the three methods (11.9%) had the worst evolution in blood pressure levels. This finding suggests that resistant hypertension cannot be attributed exclusively to low adherence.