Overcoming Adherence Barriers Through Shared Decision-Making 

Stroke recovery often requires long-term adherence to medications, rehabilitation, lifestyle modifications, and follow-up care. For some patients, managing these regimens at once after discharge can be challenging. Poor adherence can greatly affect a patient’s outcomes post-stroke, increasing the risk for recurrent stroke, disability, hospitalization, and mortality. 

Shared decision-making (SDM) is a key strategy clinicians should use in treatment planning to improve patient engagement, treatment satisfaction, and adherence. SDM can help address trust, communication, affordability, and cultural factors, all of which are essential for long-term stroke recovery. 

Why Adherence Is Particularly Challenging After Stroke 

Several factors drive poor adherence during stroke recovery, including: 

The Complexity of Secondary Prevention 

Secondary stroke prevention typically focuses on several key areas, including antithrombotic therapy when indicated, blood pressure management, lipid-lowering therapy, glycemic control when appropriate, and lifestyle modifications. These interventions can require patients and caregivers to attend multiple specialist appointments and rehabilitation visits and manage a complex medication regimen. 

Cognitive and Physical Limitations 

A stroke can cause short- and long-term mental and physical symptoms that patients now must deal with daily. Memory deficits, executive function impairments, communication difficulties, and mobility problems are just a few issues stroke survivors can face, which can make daily functioning and treatment adherence a challenge. 

Emotional and Psychological Factors 

Recovering from a stroke can have a detrimental effect on a patient’s mental well-being. They may have a fear of recurrence, post-stroke depression (PSD), anxiety, PTSD, or apathy. Caregivers can also be affected. Depending on the severity of the patient’s symptoms, stroke recovery can sometimes require around-the-clock care. With little time to rest or spend time with other loved ones, caregivers can easily burn out. If these symptoms go unmanaged in the patient or their caregiver, it can make it harder to stick to the treatment plan. 

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Unique Adherence Barriers Affecting Black Stroke Survivors 

Black Americans have historically experienced inequities in healthcare access, treatment, and outcomes. Historical injustices such as the Tuskegee Syphilis Study, along with contemporary experiences of bias and discrimination, may influence how some patients engage with the healthcare system. 

Other factors that can make treatment adherence a challenge for Black patients include: 

• Economic challenges: Pricey prescriptions, transportation barriers, and limited access to specialty care can keep some Black stroke survivors from being fully engaged in treatment. 
• Cultural and family considerations: Family involvement in healthcare decisions and differing beliefs about medications can influence treatment nonadherence, highlighting the need for culturally responsive communication. 
• Health literacy gaps: Some stroke survivors may not understand their risk of recurrent stroke, how to interpret medication instructions, or how to navigate a complex healthcare system. Clinicians can spend time during visits breaking down key treatment information and bring in additional support, such as patient navigators or advocates, to assist patients between visits. 

What Is Shared Decision-Making? 

Shared decision-making is a collaborative process where clinicians and patients work together to make healthcare decisions. It combines a clinician’s medical evidence and expertise with the patient’s personal values, goals, and lifestyle. 

Clinicians must shift from telling patients what to do to partnering with them. SDM can build patient ownership and accountability, giving them more involvement in their care. SDM is especially important in stroke care, as long-term management requires sustained engagement and recovery goals can look different for every patient. 

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How Shared Decision-Making Can Support Adherence 

Implementing SDM in stroke care offers several benefits for improving adherence. 

These include: 

• Building trust: Patients may hesitate to share struggles that affect their care. They may feel more comfortable sharing affordability concerns, transportation limitations, fear of side effects, and difficulties following complex treatment regimens with a clinician they trust. 
• Increasing patient confidence: When patients are involved in treatment conversations, they better understand the rationale for the selected therapies. This partnership can help improve self-efficacy and willingness to follow recommendations. 
• Supporting realistic care plans: Sometimes, patients are prescribed treatment regimens that they cannot realistically sustain. Tailoring the plan with attainable goals can improve adherence and overall outcomes. 

Practical Strategies for Clinicians 

Effective shared decision-making starts in the exam room. Clinicians can implement the following strategies to improve treatment adherence in stroke care: 

• Ask open-ended questions: Questions such as “What’s your biggest concern about this treatment plan?” or “What challenges might make it difficult to take these medications?” create space for patients to share challenges they face in managing their treatment regimen. 
• Incorporate family and caregivers: SDM should go beyond the patient. Involve their family and caregivers – who often manage medications and appointments – to ensure there’s a shared understanding.  
• Use teach-back methods: Ask a patient to repeat medication instructions and other key treatment information to confirm understanding and reduce confusion. 
• Simplify treatment plans: When possible, try to reduce medication burden by simplifying dosing regimens or synchronizing prescriptions. 
• Discuss costs early: If affordability is a concern, explore lower-cost therapeutic alternatives when clinically appropriate and connect patients with assistance programs. 

Technology and Team-Based Support 

Implementing technology and support networks may help improve treatment adherence for stroke survivors. 

A few examples clinicians can consider include: 

• Digital tools: Medication reminder apps, telehealth follow-ups, and remote monitoring. 
• Interdisciplinary stroke care teams: Pharmacists, nurses, social workers, and rehabilitation specialists.
• Community-based resources: Stroke support groups, community health workers, and faith-based health programs.

The Bottom Line 

Effective stroke recovery depends on more than prescribing medications or recommending rehabilitation. When clinicians engage patients as partners through shared decision-making, they can uncover barriers, strengthen trust, and create treatment plans that patients are more likely to follow.  

For Black stroke survivors, this collaborative approach may help reduce disparities in adherence while supporting better long-term outcomes. 

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