Table 1 Definition of the problem in behavioral terms

What is the problem/ behavior?

Medication non-adherence, which is associated with poor clinical and economic outcomes [20, 39], pervades all chronically ill patient populations [12, 13, 29, 40]. Post-alloSCT patients are chronically ill. With a mean of 12 medications [41], their medication regimen is complex. Most important medications in the 1st year post-alloSCT are immunosuppressants and anti-infectious medications. Co-medications (e.g., antibiotics, antivirals, fungicide) are essential to prevent and treat infections [42].

Using the ABC taxonomy, medication adherence consists of three interrelated phases: initiation, implementation and persistence [5], the latter two being relevant after alloSCT. Implementation adherence includes correct taking, timing, dosing, no drug holidays and correct food considerations (e. g., no grapefruit juice) [5, 12].

While available evidence on medication adherence in alloSCT populations is limited, we know that the prevalence of overall non-adherence to immunosuppressants in adult alloSCT patients is 64.6%: 33.3% taking non-adherence, 61.2% timing non-adherence, 4.1% dosing non-adherence, 3.2% drug holidays and 3.1% discontinuation [12]. Non-adherence to immunosuppressants is strongly associated with GvHD [12]. Less is known in view of co-medication. And while only 57% of the adult alloSCT patients report perfect medication adherence to all prescribed drugs after alloSCT [43], non-adherence can be quite selective, e.g., in one study 17% of subjects discontinued antifungal prophylaxis prematurely [44].

Therefore, it is crucial to optimize adherence, especially to immunosuppressants, in adults after alloSCT (implementation and persistence).

Where does it occur?

After alloSCT, non-adherence occurs at the patients’ homes and / or where they are at the scheduled time of medication intake.

Our contextual analysis showed that alloSCT patients within the target setting understood the importance of following their medication regimen. According to clinicians, though, medication adherence was not systematically assessed at the target transplant center. If assessed, asking the patients for intake, monitoring blood-levels or checking for rejection signs were reported to be the most used practices. Clinicians also noted a need for a qualified person, e.g., an Advanced Practice Nurse or dedicated CC, to coordinate follow-up [36].

Who is involved?

Who is our target group?

The entire health and health-related network surrounding adult patients after alloSCT (family, friends, health care professionals, ...) [36].

Community dwelling adult post-alloSCT patients