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Patient adherence – what’s the problem?


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  • 1. Patient adherence – what’s the problem? John Weinman | Professor of Psychology as applied to medicine King’s College London
  • 2. John Weinman Institute of Pharmaceutical Sciences, Kings College London PATIENT ADHERENCE What’s the problem?
  • 3. The problem of non-adherence WHO report on non-adherence • Estimated that over 30 -50% medicines prescribed for long term illnesses are not taken as directed • Similar levels for psychol treatments - e.g . Attendance/homework for CBT • If treatment is evidence- based, then this represents a loss for patients and for the health care system
  • 4. Risk of hospitalisation & non-adherence Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Medical Care. 2005;43:521-530.
  • 5. Health care cost of non-adherence
  • 6. CAUSES OF NON-ADHERENCE • Common myths • Current evidence
  • 7. Myth 1: Non-adherence is a feature of the disease Non-adherence is not linked to type of disease Low adherence rates are problematic in most chronic diseases e.g. •HIV1 •Cancer2 •Heart disease3 1Friedland, Williams. AIDS 1999;13(Suppl 1):S61–72. 2Lilleyman, Lennard. BMJ 1996;313:1219–1220. 3Horwitz et al. Lancet 1990;336:1002–1003. • Rheum. arthritis4 • Diabetes5 • Asthma6 4Hill et al. Ann Rheum Dis 2001; 869-875. 5Glasgow et al. J Behav Med 1986;9:65–77. 6Cochrane et al. Respir Med 1999;93:763–769..
  • 8. Myth 2 •Non-adherence is related to:  Gender  Educational experience  Intelligence  Marital status  Occupation / income  Ethnic background
  • 9. Most patients will be non-adherent some of the time Adherence Rates Vary Between patients Within the same patient over time and across treatments
  • 10. Myth 3 •Non-adherence is easily fixed by : -  Providing information  Providing reminders  Being authoritative  Fear arousal
  • 11. ADHERENCE INTERVENTIONS Cochrane review: Haynes et al (2008) “Current methods of improving adherence are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term disorders”
  • 12. • Need to understand types and causes of non-adherence •Need to tailor interventions to take account of this •Develop & test theoretical models
  • 14. RANGE OF POSSIBLE FACTORS :- •Poor HCP-Patient Communication •Low patient satisfaction and/or recall •Problems in planning/executive function or prospective memory •Financial or other barriers UNINTENTIONAL NON-ADHERENCE
  • 15. Beliefs influence unintentional non- adherence - forgetfulness 2 1 BCG Harris 2002; Conrad Soc Sci Med 1985;20:29–37; Ley 1988; Peterson Am J Health-Syst Ph 2003;60:657–65 2 Unni , Pat Edu Coun 2010 doi:10.1016/j.pec.2010.05.006
  • 16. Patients know what to do & how to do it BUT are reluctant to adhere because either :- •TREATMENT DOESN’T MAKE SENSE •WORRIES/CONCERNS ABOUT TREATMENT INTENTIONAL NON-ADHERENCE
  • 17. Predictors of non-adherence : Overview of Evidence
  • 18. What are the key beliefs influencing adherence to treatment? 1) Patients’ perceptions of illness 2) Patients’ perceptions of treatment
  • 19. Core beliefs about Illness • IDENTITY Abstract label eg, hypertension; asthma; arthritis Concrete symptoms that a person associates with the condition • CAUSAL BELIEFS Stress, environment, genetics, own behaviour, ageing etc • TIMELINE Perceived duration and profile eg, chronic, acute, cyclical • CONSEQUENCES Personal, economic, social • CURE / CONTROL Beliefs about the amenability to control or cure
  • 20. ILLNESS PERCEPTION & treatment adherence • Some illness perceptions are associated with treatment adherence in some conditions :- e.g. - causal beliefs predict adherence behaviour in post- MI - timeline beliefs predict preventer medication adherence in asthma etc - causal, timeline & control beliefs predict adherence to CBT for Psychosis (Freeman et al, in press) • BUT – illness beliefs per se are not strong predictors of treatment adherence – need to consider more proximal predictors (ie patients’ beliefs re. treatment)
  • 21. TreatmentIllness What are the links between illness and treatment beliefs?
  • 22. GOODNESS OF FIT between illness reps and treatment recommendations • Patients evaluate the need for treatment in the light of their understanding of illness • But some treatments may not make sense :- - exercises for back pain , balance disorder etc - daily adherence to preventer medication in asthma - smoking cessation in early cervical cancer - phosphate binding medication in ESRD • CHALLENGE TO HP – to identify these situations and to assess treatment beliefs -- develop interventions to increase adherence goodness of fit and increase motivation to adhere
  • 23. TREATMENT BELIEFS: What is the patient's perspective ?
  • 24. Beliefs about Medicines Questionnaire (BMQ) GENERAL BELIEFS about medicines as a whole SPECIFIC BELIEFS about medicines prescribed for a particular illness
  • 25. SPECIFIC BELIEFS Views about prescribed medication Necessity Beliefs about necessity of prescribed medication for maintaining health Concerns Arising from beliefs about potential negative effects
  • 26. Low adherence Doubts about NECESSITY CONCERNS about potential adverse effects Studies in asthma, CHD, cancer, renal dialysis, HIV/Aids, hypertension, diabetes Horne et al (in press), Cooper et al (2002), Horne et al (2001), Horne & Weinman (2002), Horne (2000), Horne & Weinman (1999) Horne et al (1999), Horne (1988)
  • 27. SUMMARY • Influence adherence • Have an internal logic • Are influenced by symptoms • May differ from the ‘medical view’ • May be based on mistaken beliefs/premises • May not be disclosed in consultation • Are not set in stone and can be changed Patients’ beliefs about their illness and treatment
  • 28. Implications for health care ? 1. Use the consultation to anticipate and plan 2. Interventions to :- - improve goodness of fit - improve understanding of illness and treatment
  • 29. Using the consultation to facilitate informed adherence • Check patient’s understanding of treatment and , if necessary :- • Provide clear rationale for NECESSITY of treatment • Elicit and address CONCERNS • Agree practical plan for how, where and when to take treatment • Identify any possible barriers NEEDS TRAINING OF HCPs – studies in progress
  • 30. Interventions to improve adherence Now a number of successful approaches which are based on a good understanding of patients’ beliefs, using different media, such as :- • text messaging • web-based interactive programmes • phone based support
  • 31. British Journal of Health Psychology Volume 17, Issue 1, pages 74–84, February 2012
  • 32. Method 212 patients aged 16-45 recruited from medicine package inserts or heath websites - dx asthma (not COPD), not taking preventer meds as prescribed Normal care Tailored Txt messages 18 weeks Baseline assessment Adherence assessments at 6,12, 18 weeks and 6 months
  • 33. Timeline Personal control Treatment control Illness consequenc es Medication necessity Medication concerns Targeted Texting
  • 34. Preventer Adherence Levels Meancompliancescore Compliance = puffs taken/puffs prescribed Group difference p <.01
  • 35. Percentage of patients reporting adherence at 80% or greater in control and intervention groups
  • 36. Conclusions • A better understanding of patients perspectives of illness and treatment is key to understanding adherence • This approach offers a framework for identifying and addressing the key barriers to adherence to medication • Urgent need to •1. develop interventions which can be delivered in routine consultations •2 provide patients with better access to specialist tailored interventions