Perceptions and Practicalities Approach (PAPA)™

PAPA™ provides a conceptual framework for developing effective, patient-centred solutions. Within PAPA™, non-adherence is conceptualised as a complex behaviour that has multiple causes, both unintentional and intentional, which can be summarised under two categories ‘patients they can’t or they don’t want to’.

Unintentional non-adherence

Occurs when the patient wants to take the treatment but is prevented from doing so by barriers that are beyond their control (e.g. they forget, they can’t operate the drug delivery device, they have not understood the instructions, etc.).

Intentional non-adherence

Occurs when the patient decides not to adhere. Intentional non-adherence is best explained in terms of the perceptions that shape the patient’s motivation to start and continue with treatment. In any individual, non-adherence may be both intentional and unintentional.

The PAPATM reminds us to take account of these factors when trying to help patients to adhere to appropriately prescribed medicines. It emphasizes the need to move beyond the ‘practical support’ designed to improve the patient’s ability to adherence to also address the perceptual factors affecting their motivation to start and continue with the treatment.

A comprehensive review of medication compliance, adherence and concordance commissioned by the UK National Institute of Health Research (NIHR) Service Delivery and Organisation (SDO) found that PAPA™ could be applied to explain why many adherence support interventions were ineffective and to identify how the situation might be improved. A few years after publication, the NIHR SDO review informed the content of the National Institute for Health and Care Excellence (NICE) Medicines Adherence Guidelines and informed their content.