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Horne’s Model of Adherence

Originated by: Katherine Margolis

Submitted: 26 Apr 2011

Last updated on: 26 Apr 2011

Related Health Topics: Medication adherence


Professor Rob Horne has written extensively about adherence. He categorizes non-adherence as either unintentional or intentional. Unintentional adherence would occur when a patient is prevented from taking their medicine as prescribed due to factors beyond their control (Horne, 2006). Horne reports that no clear and consistent links have been found between adherence and age, gender, intelligence, and marital status (Horne, 2008). Instead, Horne applies what he calls the Necessity/Concerns Framework. Horne found that adherence decisions are influenced by a cost-benefit assessment in which personal beliefs about the necessity for the medication for maintaining or improving health are balanced against concerns about the potential adverse effects of taking it (Horne, 2008). According to Horne, primary concerns are side-effects, long term effects, dependence, and disruption. Other concerns are specific to condition. As for necessity, many patients, especially maintenance, do not see the need to continue taking medicine if they have no symptoms.

According to Horne, Healthcare Providers (HCP) have a duty to help patients make informed treatment decisions. These decisions should be based on a clear understanding of likely benefits and risks of treatment rather than by inaccurate beliefs about their illness and the treatment (Horne, 2008). According to Horne, this should be an active process. HCPs should not just simply present information but should also talk to patients about their beliefs and work to identify concerns and potential barriers to adherence.

According to Horne, in order to facilitate adherence, both perceptual and practical concerns need to be addressed:


  • Provide an easy to understand rationale for the necessity
  • Ask for and address concerns to taking medicine and potential side effects


  • Create an easy to follow routine and remove barriers.



Bill is failing to take his asthma inhaler as prescribed. At his next appointment, his doctor clearly explains to him why he should take his inhaler and how it will help with the problems he has been experiencing (rationale). His doctor then discusses any questions or concerns Bill has about using the inhaler (concerns). Finally the doctor asks Bill about his schedule and if he can build taking his inhaler into his schedule (practical). Bill then explains to the doctor that he often forgets or runs out of time before work (barriers).


There is a Belief about Medicines Questionnaire (BMQ) that can be used to distinguish between high and low adherence (See Horne 1999).

Sample items include:

Necessity Scale:

  • My health, at present, depends on my medicine
  • My life would be impossible without my medicines
  • Without my medicines I would become very ill
  • My health in the future will depend on my medicines
  • My medicines protect me from becoming worse

Concerns Scale:

  • Having to take medicines worries me
  • I sometimes worry about the long-terms effects of my medicines
  • My medicines are a mystery to me
  • My medicines disrupt my life
  • I sometimes worry about becoming too dependent on my medicines


Horne, R., Hankins, M. and Weinman, J. (1999) The Beliefs about Medicines Questionnaire: The development and evaluation of a new method for assessing the cognitive representation of medication. Psychology and Health, 14, pp. 1-24 http://www.informaworld.com/smpp/ content~db=all~content=a788695037

Horne, R. (2006). Compliance, adherence, and concordance: Implications for asthma treatment. Chest, 130, 65S-72S. http://www.ncbi.nlm.nih.gov/pubmed/16840369

Horne, R (2008). How can we improve adherence to medicines in Europe? Slide presentation affiliated with the European Public Health Alliance. Available at: http://www.epha.org/IMG/ pdf/Rob_Horne_EP_handouts.pdf

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