3a - Adherence to Treatment (03.02.2020)

Question 1

Compliance

Answer 1

“the action or fact of applying with a wish or command”

-> not said that much anymore because it implies that the patient is not involved.

Question 2

Adherence

Answer 2

• “attachment or commitment to a person, cause, or belief”
• Adherence to long-term therapy as “the extent to which a person’s behaviour – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider (WHO)
• has a wide spectrum of behaviour (incl. under- and overadherence)

Question 3

Compliance vs Adherence

Answer 3

• “Compliance refers to the extent to which patients follow doctors’ prescription about medicine taking;
• adherence refers to the extent to which patients follow through decisions about medicine taking;
• and CONCORDANCE refers to the extent to which patients are successfully supported both in decision making partnerships about medicines and in their medicines taking.”

Question 4

Concordance

Answer 4

refers to the extent to which patients are successfully supported both in decision making partnerships about medicines and in their medicines takin

Question 5

Measuring non-adherence

Answer 5

• difficult
• There is no gold standard for measuring non-adherence, and different studies define and measure non-adherence in different ways
• limited concordance in health professionals’ judgement of patient adherence

Question 6

Methods to measure non-adherence

Answer 6

Direct methods include:

• Directly observed therapy
• Measurement of level of medicine / metabolite in the blood
• Measurement of biologic marker in the blood

Indirect methods include:

• Patient questionnaire
• Patient self-report
• Pill counts
• Rates of prescription refills
• Electronic medication monitors
• Patient diaries

=> all have pros and cons!

Question 7

Impact and consequences of non-adherence

Answer 7

• Poor health outcomes

- Increased healthcare costs

Question 8

is information enough to change behaviour?

Answer 8

NO!

- it is important but it is not sufficient and ineffective by itself

Question 9

Theories and models of non-adherence

Answer 9

UNINTENTIONAL NON-ADHERENCE
- Patient ability and resources -> Practical patient barriers to adherence

INTENTIONAL NON-ADHERENCE
- Patient beliefs and motivations -> Patient perceptual barriers to adherence

• However – there is considerable overlap between the two, e.g. health beliefs will influence “unintentional” non-adherence such as forgetting
• Need to understand the causes of non-adherence in order to recommend effective intervention

Question 10

COM-B model of Behavior

Answer 10

• interaction between Capability, Opportunity and Motivation -> causes the behaviour
• Intended as a starting point for choosing interventions that are most likely to be effective and forms the “hub” of a behaviour change wheel around which are nine intervention functions and seven categories of policy
• bidirectional relationship between everything

Question 11

Applying COM-B to medication adherence

Answer 11

• Jackson et al (2014):
• capability: psychological (e.g. cognitive function) and physical (e.g. dexterity)
• motivation: reflective (beliefs) and automatic (e.g. mood)
  = opportunity: physical (e.g. cost) and social (e.f. stigma, religion)

Question 12

Illness perception

Answer 12

• Some illness perceptions are associated with treatment adherence in some conditions, e.g.:
• Causal beliefs predict adherence behaviour in post MI (Weinman et al., 2000)
• Timeline beliefs predict preventer medication adherence in asthma (Horne, Weinman, 2002)
• Causal, timeline and control beliefs predict adherence to CBT in psychosis (Freeman et al., 2013)

Question 13

Categories of beliefs that people can have about illness and health perceptions

Answer 13

• Identity
• Consequences
• Cause
• Timeline (cyclical, acute, chronic?)
• Control or cure

Question 14

Specific beliefs and views about prescribed medication

Answer 14

• Necessity: Beliefs about necessity of prescribed medication for maintaining health
• Concerns: Arising from beliefs about potential negative effects

Doubts about necessity
+
Concerns about potential adverse effects
= Low adherence

Question 15

Patient beliefs about illness and treatment…

Answer 15

• Influence adherence
• Have internal logic
• Are influenced by symptoms
• May differ from the “medical view”
• May be based on mistaken beliefs
• May not be disclosed in the consultation
• Are not set in stone and can be changed

=> don’t make assumptions about what the person thinks and believes.
=> the beliefs are not set in stone and they can be changed

Question 16

What should healthcare professionals do in terms of adherence?

Answer 16

WHO (2003) – Healthcare providers should be able to assess the patient’s readiness to adhere, provide advice on how to do it, and follow up the patient’s progress at every contact.

Question 17

Ways to improve adherence

Answer 17

Interventions to:

• Improve understanding of illness and treatment
• Help patients to plan and organise their treatment

Using the consultation to facilitate informed adherence:

• Check the patient’s understanding of treatment, and if necessary:
• Provide a clear rationale for the necessity of treatment
• Elicit and address concerns
• Agree a practical plan for how, where and when to take treatment
• Identify any possible barriers

Question 18

Conclusions about adherence

Answer 18

• Non-adherence is common!!
• Adherence should not be assumed, but discussed with the patient
• Beliefs about illness and treatment are the strongest factors affecting adherence
• Understanding the cause of non-adherence can help identify a suitable intervention!! (also important to remember that sometimes they are not disclosed)
• COM-B model can help to explain non-adherence
• Simple strategies can be used to improve adherence