adherence to treatment

Question 1

why wont people adhere *

Answer 1

se

cost

people stop dm treatment to prevent weight gain

time

lack of percieved use

disagree with treatment

forget

too much effort

easier to not comply

Question 2

what do we mean by treatment

Answer 2

med

lifestyle interventions

Question 3

compliance def *

Answer 3

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

refers to the extent to which patients follow doctors’ prescription about medicine taking

Question 4

why is compliance less used

Answer 4

implies level of pt lack of involvement - paternalistic

Question 5

adherence *

Answer 5

refers to the extent to which patients follow through decisions about medicine taking

“attachment or commitment to a person, cause, or belief”

bring in pt involvent

Question 6

concordance *

Answer 6

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

aspirational term - adherence and compliance need to be used to see whether people are taking their drugs

Question 7

problem with chronic condition *

Answer 7

longer and more complicated condition becomes makes compliance harder

Question 8

measuring non-adhereance *

Answer 8

non-adherence is taking <80% - can be taking more

there is no gold standard for measuring adherence - different studies define different ways to do it

Macintyre et al. (2005) found limited concordance in health professionals’ judgement of patient adherence

depends whether you look at pharmacy report, self-report, whether pick up prescription or whether you pick up the medication itself

Question 9

what is the WHO definition of adherence *

Answer 9

“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”

this places emphasis on the need to differentiate adherence from compliance

Question 10

describe the spectrum of adherence *

Answer 10

might adhere in some ways and not others

can be under adherence - take meds <80%

overadherence - people can take more medicine than you recommend

Question 11

what are methods for measuring adherence *

Answer 11

direct methods

• directly observed therapy
• measurement of med in blood
• measurement of biological marker in blood

indirect methods

• pt qn
• pt self-report
• pill counts
• rate of prescription refils
• electronic med monitors
• pt diaries

Question 12

pros and cons of measuring bio marker *

Answer 12

pros - cant lie

cons - reduces trust between dr and pt, cost

Question 13

what is the scale of non-adherence

Answer 13

in developed countries - 50%

this is significant

Question 14

impact and consquences of non-adherence *

Answer 14

poor health outcomes

increased healthcare cost

viswanathan et al - 2012 - estimated that lack of adherence in USA = causes 125000deaths a yr, causes 10% of all hospital admissions, costs healthcare system $100-289billion/yr

Question 15

old theories for non-adherence *

Answer 15

early theories were based on non-adherence being due to poor communication and the impact of this on pt understanding and memory

therefore interventions were focussed on healthcare professional communication, information provision and reminders

Question 16

new theories of non-adherance *

Answer 16

appreciation that provision of information alone is not enough to change behaviour - although it is essential

unintentional non-adherence - patient ability and resources leading to practcial patient barriers to adherence - cognitive, financial, practical reason why person couldnt adhere

intentional non-adherence - patient beliefs and motivations lead to patient perceptual barriers adherence - dont understand treatment/worried about SE/personal beliefs

there is overlap between them - eg heath beliefs will influence unintentional non-adherence ie if you believe that treatment is not useful - then more likely to forget

you need to understand the causes of non-adherence in order to recommend effective intervention

Question 17

describe COM-B *

Answer 17

choose the intervention that is most likely to be effective

the performance of a behaviour is caused by interaction between capability, opportunity, motivation - explain why recommended behaviour isnt engaged

Question 18

example of application of COM-B *

Answer 18

jackson et al - considered how COM-B could be applied to the wide range of factors that have been used to describe medicine non-adherence

make clear explanatory framework for non-adherence

identify techiques to imporve adherence

bidirectional relationship between the factors

Question 19

capability in COM-B *

Answer 19

the individuals physical and psychological capacity to engage in the behabuior

physiological - capacity to engage in necessary thought processes- comprehension of disease and treatment, cognitive functioning, (eg memory, capcity, thinking), executive function (eg capacity to plan)

physical - capacity to engage in necessary physical properties - physical capability to adapt to lifestyle changes (eg diet or social behaviours), dexterity

Question 20

motivation in COM-B *

Answer 20

all brain processes that energise and direct behaviour

reflective - evaluation and plans - preception of illness (eg acute, chronic, cause) beliefs about treatment (eg necessity, efficacy, concers about adverse events, general aversuion to taking med), outcome expectancies, self-efficacy

automatic - emotions and impulses arising from associative learning and/or innate dispositions - stimuli/cues for action, mood state/disorder eg depression and anxiety

Question 21

opportunity - COM-B *

Answer 21

all factors lying outside the individual that make performance of the behaviour possible or prompt it

physical - physical opportunity provided by the environment - cost, access (availaibilty of med), packaging, physical characteristics of the medicine (taste, size, smell, shape, route of admin), regimine complexity, social support, HCP patient relationship/communication

social - cultural mileu that dictates the way we think about things - stigma of disease, fear of disclosure, religious/cultural beliefs

Question 22

illness beliefs in Leventhal’s self regulation model *

Answer 22

1. identity - what do i call my illness
2. consequences
3. cause
4. timeline - trajectory it will take and whether it is acute/chronic/cyclical
5. control/cure

Question 23

relationship of illness peception and adherence *

Answer 23

causal beliefs predict adherence behaviour in post MI - weinman

timeline beliefs predict preventer medication adherence in asthma - horne

causal timeline and control beliefs predict adherence tp CBT in psychosis - freeman

however - illness beliefs are not the strongest predictors of treatment adherence and other more proximal factuirs ie pt beliefs about treatment need to be considered - if you dont think the treatment will work, or yuou are worried about the SE - unlikely to take the medication

Question 24

beliefs about medication that influence adherence *

Answer 24

necessity - belefs about necessity of prescribed medication for maintaining health

concerns - arising from beliefs of potential SE

feed the specific beliefs - views about a prescribed med

Question 25

fundamental things about pt beliefs about treatment and illness *

Answer 25

influence adherence

have internal logic

are influenced by symptoms - people only take medication to relieve their symptoms

may differ from the medical view - belief in herbal medicine

may be on mistaken beliefs - eg fropm friend, vaccines and autism, stop taking a course of AB

may not be disclosed in the consultation

are not set in stone and can be changed

Question 26

significance of improving patient adherence *

Answer 26

improves pt safety

single most important modifyable factor that modifies treatment outcome

“increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments”

(Haynes, 2001)

Question 27

difficulty with adherence *

Answer 27

Nonadherence is often a hidden problem: undisclosed by patients and unrecognised by prescribers”

(Horne et al., 2005)

Question 28

how can we imporve adherence *

Answer 28

improve understanding of illness and treatment

help pts to plan and organise their treatment

use the consultation to fascilitae informed adherence - check the pts understanding of treatment and if necessary - provide rationale for necessity of treatment, ellict and adress concers, agree a practical plan for how, when and where to take treatment, identify any possible barriers

Question 29

improving adherence - Petrie - text *

Answer 29

a text message programe designed to modify pts illness and treatment beliefs - improves self reported adherence to asthma preventer medication

pts selected who didnt take inhaler as prescribed - baseline assessment was completed to understand reason for non-adherence

given either normal care e of tailored text messages for 18weeks

then had adherence assessments

in comparision to the control group, the intervention group improved their percieved necessity of med, belief in long term nature of asthma, percieved contol over asthma

therefore improved adherence

Question 30

improving adherence - O’carrol 2013 - stroke *

Answer 30

in previous study after 1 year 4 thing slimited adherence - younger age, concerns about medication, reduced percieved benefit, cognitive func - 6 weeks later cognitive fuinction didnt influence adherence

randomised control trial

intervention - 2 sessions aimed at increasing adherence via introducing a plan linked to environmetal cues (implementation intentions) to help establish a better medication-taking routine

eliciting and modifying any mistaken pt belied regarding medication/stroke

primary outcome was adherence to antihypertensive med using an electronic pill bottle

increased adherence on people with the intervention

A simple, brief intervention increased medication adherence in stroke survivors, over and above any effect of increased patient contact or mere measurement”