8. Adherence to treatment

Question 1

what is compliance?

Answer 1

the extent to which patients follow doctor prescriptions about medicine taking

Question 2

what is adherence?

Answer 2

the extent to which patients follow through decisions about medicine taking

Attachment or commitment to a person, cause, or belief

WHO defines adherence to long-term therapy: “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”.

Question 3

what is concordance?

Answer 3

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

Question 4

when does the risk of poor adherence increase?

Answer 4

the longer the duration of treatment is, and the more complex a regime e.g. in a long term, chronic health problem

Question 5

how is non-adherence directly measured?

Answer 5

• directly observed therapy
• measurement of level of medicine/metabolite in the blood
• measurement of biological marker in the blood

Question 6

how is non-adherence indirectly measured?

Answer 6

• patient questionnaire
• patient self-report
• pill counts
• rates of prescription refills
• electronic medication monitors
• patient diaries

Question 7

what is the average rate of adherence to treatment in long-term conditions in developed countries?

Answer 7

50%

Question 8

what is the impact of non-adherence?

Answer 8

• Poor health outcomes, which in turn leads to increased healthcare costs
• Increased mortality
• Increased hospital admissions – 1 in 10 hospital admissions are due to non-adherence
• Rejection of transplants
• Occurrence of complications
• Development of drug resistance (anti-virals)

Question 9

describe the model about intentional or unintentional non-adherence

Answer 9

UNINTENTIONAL: patient lacks ability and resources leading to practical barriers to adherence (forgets to take meds/language barrier) INTENTIONAL: patient lacks beliefs and motivations leading to perceptual barriers to adherence (treatment doesn’t make sense/worrying side effects)

Question 10

what is the COM-B model of behaviour?

Answer 10

A model of behaviour (Michie et al., 2011) which hypothesises that interaction between three components – capability, opportunity, and motivation – causes the performance of behaviour and hence can provide an explanation of why a recommended behaviour is not engaged in.

COM-B model of behaviour – the performance of a behaviour is caused by the interaction between:

• Capability – the individuals physical and psychological capacity to engage in this behaviour
• Opportunity – all factors (physical and social) lying outside the individual that make performance of the behaviour possible and prompt it
• Motivation – all brain processes that energise and direct behaviour

–Reflective and automatic

Illness perceptions further examples:

• Timeline beliefs predict preventer medication adherence in asthma
• Causal, timeline and control beliefs predict adherence to CBT in psychosis

Question 11

how can the COM-B model be applied to non-adherence?

Answer 11

Capability: the individual’s physical and psychological capacity to engage in adhering to treatment

Motivation: all brain processes that direct behaviour such as perception of illness, beliefs about treatment, outcome expectancies and self-efficacy

Opportunity: all factors lying outside the individual that make performance of the behaviour possible such as cost, access, packaging

Question 12

how can adherence be improved?

Answer 12

• improve understanding of illness and treatment
• help patients plan and organise their treatment
• check up on patients regularly.
• Ask -> Do not assume adherence!!!
• Simplify regime and packaging

–Help patients to plan and organise their treatment (practical barriers can get in the way)

• Improve interaction including communication style and presentation (especially written information)
• Identify and modify beliefs
• Involve significant others and wider network and potential to use assistive technology

–Reminder (tailored text messages)

•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 concerns that they may have regarding treatment
• Agree a practical plan for how, where and when to take treatment

Question 13

how can a consultation facilitate adherence?

Answer 13

• provide a clear rationale for the necessity of treatment
• elicit concerns that they may have regarding treatment and address these concerns
• agree a practical plan for how, when and where to take treatment
• identify possible barriers