Treatment adherence

Question 1

What is compliance?

Answer 1

The action or fact of applying with a vision or command.

Extent to which patients follow doctors’ prescription about medicine taking

Question 2

What is adherence?

Answer 2

The attachment or commitment to a person, cause or belief

Extent to which patients follow through decisions - they choose to, more empowering

Question 3

What is concordance?

Answer 3

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

Question 4

What is the WHO definition of long term adherence?

Answer 4

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 provide

Question 5

….

Answer 5

Adherence is a wide spectrum, not a category. People may adhere but not to the desired extent and some can over-adhere

Question 6

What are methods to directly measure non-adherence?

Answer 6

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

Question 7

What are methods to indirectly measure non-adherence?

Answer 7

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

Question 8

What are the consequences of non-adherence?

Answer 8

• Poor health outcomes, which in turn leads to increased healthcare costs
• It is estimated that in the USA, a lack of medication adherence: causes nearly 125 000 deaths per year, causes 10% of all hospital admissions and costs the healthcare system $100-289 billion per year

Question 9

What is intentional and unintentional non-adherence?

Answer 9

• A model was put forward to suggest that non-adherence might be intentional or unintentional
• Intentional non-adherence is a situation where the patient knows what they are supposed to do, and know how to do it. However, they are reluctant for some reason.

Unintentional non-adherence may describe a patient with a cognitive difficulty who is forgetting to take their medication. It may also occur in instances where there is a language barrier.

However – there is considerable overlap between the two (intentional and unintentional), e.g. health beliefs will influence “unintentional” non-adherence such as forgetting.

Question 10

COM-B model of non-adherence

Answer 10

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

• Capability
• Opportunity
• Motivation
• There is a bi-directional relationship between many of these elements
• 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 9 intervention functions and 7 categories of policy

Question 11

Capability - COMB model

Answer 11

• the individual’s physical and psychological capacity to engage in the behaviour
• affected by psychological and physical state
• cognitive functioning, ability to plan, comprehension, physical ability

Question 12

Motivation - COMB model

Answer 12

• All brain processes that energise and direct behaviour
• affected by reflective and automatic factors
• perception of illness, outcome expectancy, self-efficacy
• mood

Question 13

Opportunity - COMB model

Answer 13

• all factors lying outside the individual that make performance of the behaviour possible or prompt it
• affected by physical and social factors
• cost. access, packaging, regimen complexity, stigma, religious/cultural beliefs

Question 14

What 2 factors affect treatment adherence?

Answer 14

Beliefs about medication are affected by the necessity of it and any concerns they have about it

If there are doubts regarding the necessity of the medication, combined with concerns about the potential adverse effects, it is likely that adherence will be low.

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

Question 16

How can adherence be improved?

Answer 16

Interventions to:

• Improve understanding of illness and treatment (influence patient beliefs about illness)
• Help patients to plan and organise their treatment

Using the consultation to facilitate informed adherence:

• Check the patient’s understanding of treatment
• Provide a clear rationale for the necessity of treatment
• Elicit concerns that they may have regarding treatment, and addressing these concerns
• Agree a practical plan for how, where and when to take treatment
• Identify any possible barriers

Question 17

Give an example of an intervention to improve adherence

Answer 17

A text message programme designed to modify patients’ illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Patient beliefs are among factors most consistently associated with non-adherence to preventer medication.

• Inserts were given in medication packs for patients with asthma. Patients who do not take their medication as prescribed were recruited.
• A baseline assessment was done, in which an interview took place. This was to ascertain the health beliefs held by the patient that were interfering with medication interference.
• Some patients received tailored text messages over time, and others didn’t. The adherence of the two groups was studied throughout a period of time, and after the study.
• At 18 weeks, the intervention group had increased, relative to the control group, their:
• Perceived necessity of preventer medication (p<0.001)
• Their belief in the long-term nature of their asthma (p<0.001)
• Perceived control over their asthma (p<0.001)

The intervention group improved adherence over follow-up period compared with control group. There was a relative average increase in adherence over the follow-up period of 10% (p<0.001).

Percentage taking over 80% of prescribed inhaler dose (P<0.05):

• Control group: 23.9%
• Intervention group: 37.7%

Question 18

Improving adherence in stroke patients

Answer 18

A pilot randomised controlled trial

• Intervention was based on earlier research into factors predicting poor adherence in stroke survivors
• The conclusion from this research was that “interventions to improve adherence should target patients’ beliefs about their medication”.
• Intervention: 2 sessions aimed at increasing adherence via:
  o Introducing a plan linked to environmental cues (implementation intentions) to help establish a better medication-taking routine (habit)
  o Eliciting and modifying any mistaken patient beliefs regarding medication/stroke

Primary outcome was adherence to antihypertensive medication (3 months) using an electronic pill bottle.

• The intervention resulted in 10% more doses taken on schedule
• Intervention, 97%; control, 87%; 95% CI for difference (0.2, 16.2); p = 0.048)