Medication adherence refers to proper medication use according to the prescribed dosage, including treatment duration and frequency of use. It can be defined as the extent to which a patient acts according to a therapeutic regimen's prescribed interval and dose. ⁵

Patient engagement is generally low and declines over time, especially in chronic and often silent diseases such as hypertension, diabetes, dyslipidemia, and heart failure. In a study evaluating medication for secondary prevention in coronary artery disease, the rate of adequate usage did not exceed 50%. ⁶

Several factors are involved in this finding, including patient-related factors (such as sex, age, and socioeconomic status), disease-related factors (such as a lack of symptoms), health beliefs, lifestyle, and cultural habits (such as perceived severity of the problem), treatment (such as cost, side effects, and complex therapeutic regimens), institutional issues (such as health care policy and access to care), and the relationship with the health team (such as the availability of a multi-professional team). ⁷

Regarding treatment-related factors, Thom et al. ⁸ and Castellano et al. ⁹ respectively randomized 2,004 and 2,118 patients at risk of cardiovascular events to receive a single-pill fixed-dose combination of aspirin, statin, and 2 antihypertensives) vs receiving these four drugs in separate pills. Among patients who received a single pill, adherence increased 41-51%, systolic blood pressure decreased, and low density lipoprotein cholesterol decreased over the 15 months of the studies. ^{8 , 9}

The results of the SECURE study, published in the New England Journal of Medicine , support these findings, highlighting the greater efficacy of a “polypill” approach compared to usual care, mainly for vital cardiovascular outcomes. In this study, among older adults with a recent myocardial infarction, a secondary prevention treatment strategy of a polypill containing aspirin, angiotensin converting enzyme inhibitors, and statins resulted in a lower risk of major adverse cardiovascular events than usual care according to current European Society of Cardiology guidelines. These results were consistent regardless of country, age, sex, or the presence of diabetes. ¹⁰

A patient-centered approach, recognizing individual limitations and giving chronic disease sufferers control and responsibility over their condition has also been an important strategy. ¹¹

Examples of patient-focused strategies include ( Central Illustration ):

Gauging adherence and engagement is a challenge. Questionnaires validated in Brazil ¹⁷ have often been used in clinical research but are seldom applied in clinical practice. Open, detailed anamnesis and the doctor-patient relationship are fundamental in this process. The concept of patient empowerment is reflected in recent guidelines from the European Society of Cardiology and the European Society of Hypertension, which emphasize patient participation and cooperation. ¹² Considering this context, health technologies can be used to increase patient engagement. ¹⁸

More and more mobile phone apps for health management are being released, which is associated with the increasing use of smartphones and increased access to the Internet. Some of these tools include alarms reminding users to take their medication or health coaching from an artificially intelligent chatbot in patient support programs. This union of technology and health care can significantly benefit patient engagement.

Some tools can integrate healthy eating guidelines, exercise, psychosocial care, help with alcohol and tobacco cessation, monitoring vital data and recording periodic laboratory tests. The Elfie ^® app ( Figure 1 ) combines all these functions in an user-friendly software with an intuitive interface. This platform is intended for health professionals and patients, generating health data for subsequent therapeutic decision making by the health team. The app uses behavioral science, engagement, and gamification techniques, and has been validated by the Brazilian Society of Cardiology and the Brazilian Society of Diabetes. Recent guidelines and scientific evidence are its data source. Elfie ^® gamifies the patient's journey, ie, each time users monitor their blood pressure, cholesterol, glycemia, take their medications, or exercise, they receive points that can be exchanged for health-related products or benefits. This app is part of a patient support program based on the COACH trial. ¹⁹ Other studies using this model have shown that hypertension self-management programs based on mobile technology can support long-term blood pressure control and detect very high blood pressure, improving real-world blood pressure monitoring. ²⁰

Figure 1 HbA1c : hemoglobina glicada.

There is also good evidence for the efficacy of a combination of educational interventions (eg, cognitive, motivational, and behavioral). National non-governmental organizations have begun initiatives of this type, especially for people with diabetes, family members, health professionals, and individuals interested in learning about diabetes and cardiovascular complications. Thus, everyone can, in their own way, help improve treatment adherence and engagement.

Non-profit agencies can play a fundamental role in educating people with chronic non-communicable diseases through online or in-person programs to address issues related to the disease, the patient, and society. Using these tools, patients can adapt and modify their lifestyle habits to reduce risks and improve control of chronic diseases. Examples include the National Association for Diabetic Assistance (ANAD); ADJ Diabetes Brasil, São Paulo; Diabetes Association of Greater São Paulo (ADIABC); Institute for People with Diabetes (IPD), Paraná; Diabetic Association of Lagoa (ADILA), Rio de Janeiro; and the Voices of Advocacy coalition. ²¹

Polypharmacy is another common complaint in doctors’ offices, and patients and doctors should be aware of how medications are being taken: the time, the frequency, and whether they are being taken before or during meals. ²² In light of this problem, some startups have sought to streamline the purchasing and organization of medication regimens for patients. Pioneers in this effort include SafePill and FAR.ME; these companies send a personalized box each month to users with the pills portioned into individual packets. Each packet is sequentially labeled with the day and time each dose should be taken. These companies also have smartphone apps that remind users to take their medications and record confirmation that it has been taken.

Another advantage of these companies is that they guarantee the best price for medications and have a team of pharmacists to answer questions and modify the regimen when the patient’s medical team makes any prescription changes.

The health belief model has had excellent results in clinical practice. According to this model, greater patient engagement in a given behavior results from the interaction between self-perception of one’s health condition (or the risk of developing some disease) and the self-perceived benefits of adopting a healthy attitude. ²³

Using a device to continuously monitor glucose, for example, could directly improve clinical outcomes through greater engagement, since it would allow the patient to see impact of glycemia and their daily progress regarding food, exercise, and emotional aspects, thus leading to positive behavioral change.

A study found that glycated hemoglobin was reduced in patients with type 1 and type 2 diabetes who used a Freestyle Libre monitor (Abbott Laboratories, Abbott Park, IL, USA), even without modifying their therapeutic regimen. ¹

There are several barriers to managing chronic diseases, such as insufficient knowledge about the condition, financial difficulties, and the side effects of medications. Technological innovations can be used to meet needs on an individual level and facilitate daily life.

On the other hand, attention should also be paid to patient inexperience with health apps, since they may give a false impression of poor performance. It is up to health professionals to assist and instruct each patient, answering questions and encouraging their use.