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iBSC Health and Illness Across the Lifespan > Session Nine (Non-Adherence) > Flashcards

Session Nine (Non-Adherence) Flashcards

1
Q

What are the differences between Fulfilment, Compliance and Adherence?

A

Medication Fulfilment = the process by which a person actually acquires their medication, e.g. picking up their prescription from the pharmacy

Compliance to Treatment implies a person is following a doctor’s orders without any involvement

Adherence to Treatment implies they are sticking to an agreed upon line of treatment, emphasises the role of the patient during the agreement phase.

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2
Q

What does 2009 NICE guidelines say about adherence?

A
  • Should no longer be viewed as a problem with the patient
  • Problem lies with the failure to agree to a prescription in the first place or a failure to identify and provide the support a patient needs to carry out the treatment.
  • Represents a fundamental limitation in the delivery of healthcare.
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3
Q

What is included under the term Adherence?

A
  • Taking medications
  • Attending follow up appointments
  • Lifestyle changes
  • Monitoring tests
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4
Q

What are the 3 types of non-adherence?

A
  • Primary NA/ Fulfilment: Not filling out a prescription
  • Secondary NA: Overusing it, Missing doses, Changing dose amount or frequency, Changing the timing of doses
  • Non-Persistence: Not continuing the treatment for the prescribed duration
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5
Q

What proportion of therapies are not adhered to?

A

30-50% of all medicines prescribed are thought to not be taken as directed. These numbers are probably worse for lifestyle changes and chronic, long term conditions.

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6
Q

Why is increasing adherence so important?

A

Better adherence leads to:

  • Slowed disease progression
  • Reduced morbidity and mortality (200k/year due to NA)
  • Reduced disability
  • Increased QoL
  • Reduced healthcare costs (potentially wasting 4 billion pounds a year)
  • Reduced unnecessary treatment escalation
  • Reduced societal and workforce costs

Thought that increasing adherence would have a greater benefit than any new implementation

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7
Q

What are some recognised barriers to treatment adherence?

A
  • Side effects
  • Method of delivery
  • Ability to collect drugs
  • Lack of immediate benefit
  • Symptoms disappearing before treatment complete…
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8
Q

What are the important myths around who doesn’t adhere to treatment?

A
  • NA has nothing to do with the disease, it’s seen in all conditions no matter how serious or long term
  • NA has nothing to do with the SE factors of the patient, significant variation seen in all demographics, as well as in individuals relating to different medications/ diseases/ times in their lives.
  • NA can’t be ‘easily’ fixed by providing adequate information, or reminders, or threats or fear.
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9
Q

What is the evidence regarding the link between complexity of regimen and Adherence?

A

Mixed. Claxton et al 2001:

  • Showed that simplifying a regimen can be helpful for some patients
  • However, did not totally resolve NA issues
  • NA appears to arise more from difficulty of fitting medication into daily life than complexity per se
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10
Q

What is intentional and unintentional non-adherence?

A 
INA = Deliberately choosing not to take a medication.
UINA = Forgetting/ not being able to take a medication

Important to remember that for many patients the reason they don’t take their meds falls somewhere between the two e.g. more likely to forget (UI) a medication you don’t agree with (I)

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11
Q

What is important to remember when dealing with Intentional NA?

A

Decision may seem illogical to us, but the patient will certainly have made a logical decision not to take their medications. Getting to the route of this decision making process might be key to getting over this NA issue.

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12
Q

How can we assess a patient’s adherence to medication?

A
  • Self report methods
  • Direct observation of treatment
  • Can look at pharmacy dispensing records (although this only tells us about fulfilment not adherence)
  • Pill counts
  • Can do blood tests
  • Medication Event Monitoring Systems (MEMS)
  • Intelligent Drug Administration Systems
  • Ingestible sensors
  • Smart blisters that send a signal when popped
  • By clinical outcome
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13
Q

McHorney (2008) Reviewed all factors believed to be associated with NA, with what factors did he find WEAK evidence for an association?

A

DEMOGRAPHIC FACTORS:

  • Gender
  • Income
  • Age
  • Race
  • Personality
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14
Q

McHorney (2008) Reviewed all factors believed to be associated with NA, with what factors did he find MODERATE evidence for an association?

A

COGNITIVE or PSYCH FACTORS:

  • Cognitive ability
  • Depression
  • Social support
  • Coping skills
  • Number of medicines
  • Disease seriousness beliefs
  • Health literacy
  • Locus of control
  • Self efficacy
  • Trust in HCP
  • Symptom experience
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15
Q

McHorney (2008) Reviewed all factors believed to be associated with NA, with what factors did he find STRONG evidence for an association?

A

Largely ILLNESS/TREATMENT FACTORS:

  • Concerns about treatment e.g. fear of SEs
  • Beliefs about illness (cause, timeline)
  • Cost of therapy
  • Necessity (including perceived)
  • Perceived drug efficacy

Actually provides pretty good evidence or every model of NA tbh.

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16
Q

What is a common issue with self reported measures of adherence?

A
  • Patients quite often lie about how much they adhere to therapy
  • Self-representation bias
  • Can work around this by using a scale such as the Medication Adherence Report Scale (MARS) which attempts to normalise NA in order to elicit a more honest response
  • Rather than asking do you adhere its more do you forget and if so how often
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17
Q

What is the Perceptions And Practicalities Approach to NA?

A

Framework that explains NA in terms of practical factors and perceptual factors:

  • UI NA is driven by a patient’s capacity and recourses, their PRACTICAL factors
  • I NA is driven by a patient’s motivations, beliefs and preferences, their PERCEPTUAL factors
18
Q

What are some examples of Practical factors that might get in the way of adherance?

A
  • Manual dexterity
  • Forgetfulness
  • Inability to pay for medication
19
Q

What are some examples of Perceptual factors that might get in the way of adherance?

A
  • Reasons for needing medication
  • Efficacy of supposed treatment
  • Concerns about SEs
  • Relationship with HCP
20
Q

How does the PAPA flow chart work?

A
  • Beliefs about Illness and Medication make up the Perceptions about the illness
  • If these line up then the patient has Intent to take medication
  • Next step is whether they are able to use medication
  • If yes then Adherence

Essentially claims that Perceptions create Intent, which leads to Adherence unless Practicalities get in the way

21
Q

What is the COM-B model of behaviour?

A
  • Capability, Opportunity and Motivation all influence behaviour
  • All also influence each other
  • Capability = “psychological and physical capacity to engage in a behaviour”
  • Opportunity = “all factors lying outside of the individual that make a behaviour more or less likely”
  • Motivation = “all brain processes that energise and direct behaviour”
22
Q

What are some factors that fall into capability in COM-B?

A

Psych:

  • Comprehension of disease and treatment
  • Cognitive functioning
  • Executive function

Physical:

  • Strength
  • Dexterity
23
Q

What are some factors that fall into motivation in COM-B?

A

Reflective (relating to evaluation and plans)

  • Perception of illness
  • Beliefs about treatment
  • Outcome expectancies
  • Self-efficacy

Automatic (relating to more immediate situation)

  • Mood
  • Stimuli/ Cues
  • Habits
24
Q

What are some factors that fall into opportunity in COM-B?

A

Physical:

  • Cost
  • Access
  • Packaging
  • Regimen complexity

Social:

  • Stigma of disease
  • Social support
  • Patient-doctor relationship
  • Religious or cultural beliefs
25
Q

What factors did Howard Lowenthal suggest influenced how a patient perceives their disease?

A

ILLNESS PERCEPTIONS:

  • Identity (what is this and what symptoms are associated with this)
  • Timeline (how long will this last, is this something that will come and go)
  • Consequences (what does this mean for me, for my family)
  • Cause (what made this happen)
  • Control/Cure (what can I do? will this work)

IT CCCC

26
Q

What are the key beliefs that affect adherence?

A
  • Beliefs about the illness (identity, consequences, timeline, control/cure, cause)
  • Beliefs about the treatment (includes both beliefs about medicine as a whole and this specific form of treatment (necessity and concerns)
27
Q

According to the Necessity-Concerns Framework, what influences how a patient feels about a prescribed medication?

A
  • Beliefs they have about how necessary this prescribed medication is for their health (NECESSITIES)
  • Beliefs about potential negative effects (CONCERNS)

Combine to make up the complex image of a patient’s specific beliefs around a medication

28
Q

What evidence is there to support the Necessity-Concerns Framework?

A

Horne et al (2013):

  • Meta-analysis of NCF and NA
  • 94 studies
  • Found higher adherence was associated with; increased necessity beliefs, decreased concern beliefs
  • Good evidence for NCF as a predictive framework for adherence
  • Study also showed that many patients who have high need and concern beliefs, these will often take the medication but at a lower dose (again, logical to them but perhaps not us)
29
Q

What effects can sensations of personal control and emotional response have on adherence?

A

Both can have either positive or negative effects on adherence, depending on the person.

30
Q

What is the INAS and what was it developed for?

A
  • International Non-Adherence Scale.
  • Works off the NCF, but accepts that this doesn’t explain 100% of NA and therefore expands on it by focusing on IDENTITY
  • Works on the idea that some patients reject the identity associated with the illness, prioritise maintaining normality above all else
  • Choose not to adhere as treatment is a reminder of their condition
31
Q

Outline the Health Belief Model (Rosenstock, 1974):

A
  • Demographic and Psychological characteristics affect…
  • Health motivation, Perceived threat and Assessment of risk vs benefit
  • All of which affect Action
  • Perceived threat = how a patient thinks of their susceptibility and severity
  • Risk vs Benefit assessment looks at perceived benefits and perceived barriers
32
Q

What criticisms have been made about the Health Belief Model and Theory of Planned Behaviour?

A

Too rational, imply humans make their decisions on a pro/con basis when in fact we are for more emotional than that

33
Q

Outline the Theory of Planned Behaviour?

A
  • Attitudes, Subjective Norms and Perceived Control affect…
  • Behavioural Intent, which then affects
  • Behaviour

However, we are unclear what lies between behavioural intent and actually performing the behaviour, only what drives intent.

34
Q

When does HBM say an action is likely to occur?

A
  • Perceived threat is high
  • Benefits outweigh barriers
  • Cues in place
35
Q

When does TPB say an action is likely to occur?

A
  • People important to you support the behaviour (norms)
  • Behaviour is considered positive (attitudes)
  • Confidence to perform behaviour is high (perceived control)
36
Q

Broadly, what are the two things we can do to improve adherence?

A
  • Use the consultation to anticipate and plan

- Incorporate specialist interventions

37
Q

What can be done in the consultation to improve adherence?

A
  • Check patient understanding of treatment
  • Provide clear rationale for NECESSITY
  • Elicit and address any CONCERNS
  • Agree a practical plan for how, where and when to take treatment
  • Identify any possible facilitators and barriers
38
Q

What are the NICE recommendations for changing a behaviour?

A
  • Goals and Planning: Agree goals, develop action plan, develop coping plans
  • Feedback and Monitoring: Encourage self-monitoring of behaviour and outcome, provide feedback on behaviour and outcome
  • Social support: Friends, relatives, colleagues, buddies to provide practical help, emotional support, praise, reward
39
Q

What specialised interventions exist to try and boost adherence?

A
  • Specialised intervention programmes
  • Text/phone/web based
  • Targeting of patient beliefs
40
Q

What did the Petrie et al (2012) study show about specialist adherence interventions in asthma?

A
  • Identified 216 patients with, aged 16-45 with low levels of adherence
  • Given baseline assessment
  • Half sent into normal care half received tailored text messages
  • Text messages targeted the specific reason for the patient’s NA e.g. if they believe they don’t need to use it when they don’t have symptoms they’ll receive a text saying your asthma is always present
  • Adherence measured by phone calls at 6 weekly intervals initially then at 6 and 9 months
  • A measured as puffs taken/ puffs prescribed
  • 80%+ is considered adherent

Findings:

  • Significant positive change in illness perceptions and treatment beliefs
  • Perceived duration of asthma increased
  • Perceived control increased
  • Perceived necessity of treatment increased
  • Adherence remained high at 6 and 9 months
41
Q

What did the Bushnell et al (2010) study show about adherence in stroke patients?

A
  • Performed as 25% of patients discontinue a medication within 3 months
  • Cognitive impairments common post-stroke
  • Mix of UI and I NA
  • Selected patients with sub-optimal A 3 months post first incident of stroke/TIA
  • Gave them two sessions; 1 targetting how best to make sure they take them e.g. with action plans stuck on bathroom mirror (UI NA), and 1 session targeting beliefs about condition, necessity and concerns around meds (I NA)
  • Adherence measured using MEMS (looked at % of pills taken, days with correct pill number taken and how close to agreed upon time the pills were taken)
  • Found both beliefs and adherence had improved by end of study
  • Suggests there is a role for specialist intervention targeting UI and I NA in those who struggle to adhere to therapy.

iBSC Health and Illness Across the Lifespan (12 decks)

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