How many of you have even been prescribed antibiotics? How many of you have stopped a course of antibiotic prematurely?
To begin, how big a problem is poor adherence? It is now established that approximately 60% of patients may not be adhering to long-term treatment regimens 1-2 years later. A good predictor of long-term adherence is adherence at entry into treatment. In other words, adherence behaviour is fairly stable. The distribution of adherence is tri-modal.
This pie chart illustrates this point. Surveys suggest that about 1/3 of the population are good adherers, 1/3 partially adhere, and 1/3 are poor adherers.
Only about 50% of patients who claim to be adherent are adherent; and clinicians tend to over-estimate adherence in their patients by about 50%. Thus, the evidence suggests that we likely believe that our patients are more adherent they actually are.
Studies of patients ’ reported reasons for deliberate non-adherence have identified the following reasons: forgetfulness, financial, feeling sick, feeling well, laziness, too busy, and life events or life circumstances. Knowing these common reasons can enable you to be armed with some helpful hints about how to overcome these problems. For example, with forgetfulness you help the patient identify ways to remind himself/herself. Financial considerations might influence your choice of which medications to prescribe, etc.
Give example of hypertension and wanting to stop medication to see if BP remains normal.
Psychosocial factors for poor adherence have also been identified. These include knowledge and beliefs about adherence, personality factors, and affect or mood states.
Some psychosocial factors have been identified as influential in shaping adherence behaviour. These are knowledge or beliefs and certain coping styles. I ’ ll start with knowledge and beliefs. Beliefs regarding disease risk and beliefs regarding one ’ s confidence in the effects of treatment influence one ’ s motivation to adhere. Faulty beliefs about the health problem and treatment effectiveness can arise simply from lack of knowledge about the health problem or its treatment. The other two health beliefs reflect ways of coping with the anxiety related to the health problem. For example, one way people cope with threat is to deny it or under-estimate its consequences. In this case, education about the condition is not enough, it is also important to help the individual deal with his/her anxiety more effectively so that he/she does not need to cope by denial. A third factor is beliefs regarding one ’ s invulnerability. An American researcher, Neil Weinstein, has labeled this condition unrealistic optimism. Unrealistic optimism is the belief that one is at lower risk of suffering the negative effects of the health risk or problem than one ’ s peers. As it turns out, the norm is to be somewhat unrealistically optimistic ( “ Oh, that won ’ t happen to me). Arguably, it is the way we maintain hope. Adherence difficulties, however, arise when one is so unrealistically optimistic that one feels fairly immune to the disease risk.
Past behaviour is an excellent predictor of future behaviour. For example….Notwithstanding these observations it is also very important to recognize that in changing behaviour, individuals proceed through different stages of motivational readiness. Thus, as practitioners it is critical that we a) not give up on expecting someone to change; and b) we recognize that change can progress or regress. In other words, relapse is the norm. More about this later.
Why patients do not adhere tomedical advice. Health Psychology
Compliance Adherence Concordance – Degree to which the patient carries out the behaviours the physician recommends (e.g., taking medication).
Extent of non-adherence problemDifficulties with assessing it: – Many different kinds of medical advice to which one could adhere – Can violate advice in many different ways – Difficult to know if patient complied (50/50 chance that the physician’s judgment of the patient’s adherence is accurate).
Adherence 60% of patients may not be adhering to long-term treatment regimen 1-2 years later even in cardiac patients medication adherence over time is poor (i.e., 40% nonadherent 3 years later) Good predictor of long-term adherence is adherence at entry Distribution of adherence is tri-modal
Distribution of Adherence Adherent Partial Adherent Non-adherent 1/31/3 1/3
Measuring Adherence in Clinical Practice Physician impression overestimates patient- adherence by about 50% (Caron, 1985). Electronic monitors of pills taken are impractical in routine clinical practice. Bio-chemical measures also have limitations Self-report methods are good at detecting those who admit to adherence difficulties but will miss- classify about 50% patients who deny problems or who are unaware of a problem.
Forms of Non-AdherenceForgetting a doseDeliberately skipped dosesOccasional day or even week off therapyStopped therapy
Patients’ Reasons for Not Adhering Forgetfulness (e.g., restaurant, trip) Financial (wait until pay day, take 1/2 dose to delay renewing prescription) Feeling sick Feel well (rare reason) Lazy about going to the drug store Too busy - forget Life events, stress (e.g., death in family) Don’t believe in the treatment Confused about dosage
Rational Reasons for Non-adherenceHave reason to believe the treatment isn’tworkingFeel that side-effects are not worth the benefitsof treatmentDon’t have enough money to pay for treatmentWant to see if the illness is still there whenthey stop the treatment
Non-adherence: Characteristicsof the regimen Complex regimens have low adherence Adherence decreases with duration of the regimen Expense decreases adherence
Non-adherence: Cognitive-Emotional FactorsPatients forget much of what the doctor tellsthemInstruction and advice are forgotten morereadily than other kinds of informationThe more patient is told, the higher thelikelihood of forgetting more.Patients remember what they are told first andwhat they think is most important.
Non-adherence: Cognitive-Emotional FactorsMore intelligent patients do not remember morethan less intelligent patientsOlder patients remember as much as youngerpatientsModerately anxious recall more than low orhigh anxious patientsThe more medical knowledge the patient has,the more he/she will remember.
Non-Adherence: Psychosocial Factors Social support Personality - Dispositional Attitudes Affective State Knowledge and attitudes
Non-Adherence: Knowledge/Beliefs Lack of knowledge Denial or trivialization Perceived invulnerability Necessary but not sufficient
Non- Adherence - Behaviour Early adherence, e.g., within first month of initiating therapy is an excellent predictor of later adherence, even 7 years later (Dunbar & Knoke, 1986) The more similar the predictor behaviour to the predicted behaviour, the higher the correlation. Generally, little evidence for a health-oriented behaviour pattern.
Whey don’t people adhere? Did not understand the treatment regime (inadequate or non-existent instructions) Forget Side effects Lack of commitment Travel away from home Depression Feel better – did not see need for completion
Why do people fail to takemedicines properly? Non-adherence leads to •ineffective treatment •Additional health care expenditure •Anti-biotic resistance
How can services can help adherence? Spend time explaining the importance of adherence and help them to choose strategies that can help them to adhere More appropriate drug regimes (e.g. shorter times for completion of treatment) More acceptable presentation e.g. sugar coated anti-malarials, syrups etc. Suitable packaging – blister packaging – lay-out Instructions with the packaging - simple words/pictures Involve partners so they can remind their partners
Medicine labelling/packagingUsed to explainDose, timing, side effects, things to avoid while takingmedicinesCommunication depends on:Size/clarity of lettersLanguage and complexity of wordsLiteracy of audience and familiarity with medical termsQuality/comprehensibility of pictures and picturesymbols e.g. sun/moon for time of day
Increasing Patient Adherence Use clear (jargon free) sentences Repeat key information Recruit sources of support Tailoring the regimen Providing prompts and reminders Self-monitoring Behavioural contracting
Strategies that people can use toremember dosesIntegrate regimes into daily routinesHave a checklist for recording doses takenCount out daily doses as week at a timeUse a pill box, alarm or daily planner
Examples of methods methodsused to encourage adheranceLeaflets, instructionsBlister packagingA programme in SouthAfrica used textmessaging to remindpeople to take theirtuberculosis medicinesVisual aids likecalendarsPoster warning dangersof combining drugsand alcohol(Nicaragua)
Poster put up on thewalls of clinics in UK toprevent unnecessary useof antibiotics
Extent of problem Taylor (1990) 93% of patients fail to adhere to some aspect of their treatment.
Extent of problem Sarafino(1994) People adhere to treatment regimes reasonably closely 78% of the time. Sarafino found the average adherence rates for taking medicine to prevent illness is 60% for short and long term regimes. Compliance to change ones diet or to give up smoking is variable and low.
Extent of problem Compliance with chemotherapy is very high among adults with estimates of better than 90 percent of patients complying with the treatment.
Extent of problem Non compliance takes many forms. Some patients do not keep appointments; others do not follow advice. Many patients fail to collect their prescriptions, discontinue medication early, fail to change their daily routine, and miss follow-up appointments (Sackett and Hayes, 1976).
Kent and Dalgleish (1996) Kent and Dalgleish (1996) describe a study in which many parents of children who were prescribed a ten-day course of penicillin for a streptococcal infection did not ensure that their children completed the treatment. The majority of the parents understood the diagnosis, were familiar with the medicine and knew how to obtain it.
Kent and Dalgleish (1996) Despite the fact that the medication was free, the doctors were aware of the study and the families knew they would be followed up, by day three of the treatment 41% of the children were still being given the penicillin, and by day six only 29% were being given it.
(Ley, 1997). The costs associated with non-adherence can be high. The illness may be prolonged in the patient and he or she may need extra visits to the doctor. These are not the only costs, however, as the person may have a longer recovery period, might need more time off work or even require a stay in hospital.
(Ley, 1997). Non-adherence may lead to as much as 10% —20% of patients needing a second prescription, 5%—10% visiting their doctor for a second time, the same number needing extra days off work, and about 0.25 %—1% needing hospitalisation (Ley, 1997).
Methodological problem Percentages are overestimated because patients who tend to volunteer for these studies would be more likely to be compliant.
Methodological problem Patients often lie about their level of adherence, so as to present a good impression of themselves. It has been reported in the press that those patients who smoke may be afforded a low level of priority, when they are in need of a transplant. Patients might lie about their smoking, to avoid such discrimination.
Why patients do and dontadhere to advice Patients are less likely to change habits than heed medical advice to take medicine (Haynes, 1976).
Why patients do and dontadhere to advice Patients who view their illness as severe are more likely to comply (Becker & Rosenstock, 1984). Notice it is how the patient views the seriousness of the illness, not what the physician thinks!
Why patients do and dontadhere to advice Doctors tend to blame their patients for non-adherence, attributing their behaviour to characteristics of their patients (mental capacity or personality traits) - Davis (1966).
Why patients do and dontadhere to advice Research has shown that it is not the patients personality that predicts non- adherence, but a combination of factors arising out of the doctor - patient relationship (e.g. Ley 1982). Factors such as age and gender are predictive of compliance, depending upon what instructions are to be complied with.
Classic experiments - Milgram(1963) and Asch (1955. Milgrams experiment demonstrated thatordinary people will obey authority figures,to the extent that they would administerpotentially lethal electric shocks to a mild-mannered victim. Aschs experiment demonstrated thatpeople will agree with others even though itis obvious others are wrong.
(Haynes 1976). If medication is prescribed over a long time, its more likely to be discontinued early (Haynes 1976).
Patient satisfaction Ley (1988) reviews 21 studies of hospital patients and found that 28% of general practice patients in the UK were dissatisfied with the treatment they received. Dissatisfaction amongst hospital patients was even higher with 41 per cent dissatisfied with their treatment.
Patient satisfaction The dissatisfaction stemmed from affective aspects of the consultation (e.g. lack of emotional support and understanding), behavioural aspects (e.g. prescribing, adequate explanations) and competence (e.g. appropriateness of the referral, diagnosis).
Patient satisfaction It was found that patients were "information seekers" (i.e. wanted to know as much information is possible about their condition), rather than "information blunters" (i.e. did not want to know the true seriousness of their condition).
Patient satisfaction Over 85% of cancer patients wanted all information about diagnosis, treatment and prognosis (the chances of treatment being successful) (Reynolds et al., 1981).
Patient satisfaction 60 to 98% of terminally ill patients wanted to know their bad news (Veatch, 1978).
Patient satisfactionOlder research had found that a small butsignificant group did not want to be giventhe truth for cancer and heart disease(Kubler-Ross, 1969).These findings could be due, in part, to theattitudes that prevailed during the lateSixties.Research suggests that attitudes havechanged since then.
TESTING A THEORY -PATIENT SATISFACTIONA study to examine the effects ofa general practitioners consultingstyle on patient satisfaction(Savage and Armstrong 1990).
Methodology Subjects The study was undertaken in group practices in an inner city area of London. Four patients from each surgery for one doctor, over four months were randomly selected for the study.
Methodology Patients were selected if they were aged 16- 75, did not have a life-threatening condition, if they were not attending for administrative/preventative reasons, and if the GP involved considered that they would not be upset by the project.
Methodology Overall, 359 patient were invited to take part in the study and a total of 200 patients completed all assessments and were included in the data analysis.
Design The study involved a randomised controlled design with two conditions: (1) sharing consulting style and (2) directive consulting style. Patients were randomly allocated to one condition and received a consultation with the GP involving the appropriate consulting style.
Procedure A set of cards was designed to randomly allocate each patient to a condition. When a patient entered the consulting room they were greeted and asked to describe their problem. When this was completed, the GP turned over a card to determine the appropriate style of consultation.
Procedure Advice and treatment were then given by the GP in that style. For example, the doctors judgement on the consultation could have been either This is a serious problem/I dont think this is a serious problem (a directive style) or Why do you think this has happened? (a sharing style).
Procedure For the diagnosis, the doctor could either say You are suffering from. .. (a directive style) or What do you think is wrong? (a sharing style). For the treatment advice the doctor could either say It is essential that you take this medicine (a directive style) or What were you hoping I would be able to do? (a sharing style).
Procedure Each consultation was recorded and assessed by an independent assessor to check that the consulting style used was in accordance with that selected.
Measures All subjects were asked to complete a questionnaire immediately after each consultation and one week later. This contained questions about the patients satisfaction with the consultation in terms of the following factors:
Measures The doctors understanding of the problem. This was measured by items such as I perceived the general practitioner to have a complete understanding . The adequacy of the explanation of the problem. This was measured by items such as I received an excellent explanation.
Measures Feeling helped. This was measured by the statements I felt greatly helped and I felt much better. The results were analysed to evaluate differences in aspects of patient satisfaction between those patients who had received a directive versus a sharing consulting style.
Measures In addition, this difference was also examined in relation to patient characteristics (whether the patient had a physical problem, whether they received a prescription, had any tests and were infrequent attenders).
Patient Satisfaction The results showed that although all subjects reported high levels of satisfaction immediately after the consultation in terms of doctors understanding, explanation and being helped, this was higher in those subjects who had received a directive style in their consultation.
Patient SatisfactionIn addition, this difference was also foundafter one week. When the results were analysed to examinethe role of patient characteristics onsatisfaction, the results indicated that thedirective style produced higher levels ofsatisfaction in those patients who rarelyattended the surgery, had a physicalproblem, did not receive tests and receiveda prescription.
Patient understanding Boyle (1970) asked patients to define a range of different illnesses and found the following:
Boyle (1970)Illness to be defined % correctArthritis 85Bronchitis 80Jaundice 77Palpitations 52
Roth (1979) Roth (1979) found that although patients understood that smoking is causally related to lung cancer, 50% thought that lung cancer caused by smoking had a good prognosis for recovery. It was also found that 13% of patients thought that hypertension could be cured by treatment when it can only be managed.
Patient recall Bain (1977) tested recall of a sample of patients who attended a GP practice. The following was found:
Instruction to be % unable to recallrecalledThe name of the 37prescribed drugFrequency of dose 23Duration of 25treatment
Crichton et al. (1978) Crichton et al. (1978) found that 22% of patients had forgotten their advised treatment regimes after visiting their GPs.
Ley (1989) Ley (1989) found that the following factors increased recall of information: Lowering of anxiety Increased medical knowledge Higher intellectual level (but see below) Importance and frequency of statements Primacy effects Age has no effect on recall success.
(DiMatteo & DiNicola 1982). Cognitive and emotional factors in patients recall of information (DiMatteo & DiNicola 1982).1. Patients forget much of what is told to them2. Instructions and advice are more likely to be forgotten than other information3. The more a patient is told the greater the proportion a patient will forget4. Patients remember a) what they are told first and b) what they consider to be important5. Prior medical knowledge aids recall.
(DiMatteo & DiNicola 1982).1. Intelligence is not a factor (but see above)2. Age is not a factor3. Moderately anxious patients recall more than highly anxious patients
Homedes (1991) 200 variables affect compliance. Characteristics of the patient Characteristics of the treatment regime Features of the disease The relationship between the health care provider and the patient The clinical setting.
Becker and Rosenstock (1984)1. Evaluating the threat. Seriousness and vulnerability are taken into account. Being overweight would make you more vulnerable to a heart attack. A heart attack is serious. The patients relative youth would mean he or she is less vulnerable. And so on.
Becker and Rosenstock (1984) Seriousness and vulnerability being high would be a good predictor of the likelihood of action. However, there are other factors that need to be taken into account. A recent media campaign would be a cue to action. The patient would need to work out the costs and benefits of the treatment as well.
Becker and Rosenstock (1984)2 Cost-benefit analysis. – Will the benefits outweigh the costs? – Barriers (or costs) might be financial, difficulty getting to a health clinic, not wanting to admit that they are getting old. – Benefits would be improved health, less risk from illness and less anxiety.
(Becker 1976). Perceptions of severity and susceptibility by the patient are related to compliance (Becker 1976).
(Becker 1976). Patients who believe they are likely to become ill and that this eventuality would have negative consequences are more likely to take some action. Simple beliefs regarding the likelihood that medication will improve the patients condition are very potent determinants of compliance (Becker 1976).
Actual severity of an illness is not related tocompliance, but patient perception ofseverity is.
Abraham et al (1992) Abraham et al (1992) studied 300 sexually active Scottish teenagers. The seriousness of AIDS and the perceived vulnerability of contracting the illness were not the factors that influenced the teenagers. The awkwardness of use and the likely response from their partner, were seen as costs that outweighed the benefits.
Abraham et al (1992) The teenagers therefore tended not to use condoms! It would make sense to concentrate advertising campaigns on the barriers to condom use.
Problems It is difficult to assess the health belief model as it is difficult to measure variables such as perceived susceptibility. Habits, such as cleaning your teeth are not easily explained by the model. The model has limited predictive value, but can be useful when trying to explain somebodys behaviour.
(Becker 1974). Any question of safety of treatment, side effects, or distress associated with treatment become very powerful suppressers and reduce the likelihood that patients will do as they were told (Becker 1974).
(Becker 1974). The Health Belief model is a comprehensive model. Revisions in the model have expanded its range to include intentions as well as beliefs (Becker 1974). Other models that are less comprehensive are the theory of reasoned action, protection motivation theory, Naive health theories and subjective expected utility theory.
Naive health theories. Patients often develop their own incorrect theories about their illnesses. Such theories develop because a particular behaviour has become erroneously associated with an improvement in their condition.
Naive health theories. Such beliefs interfere with the understanding of the doctors instructions. The instructions are interpreted so as to accord with their naive health theory (Bishop and Converse, 1986).
Naive health theories. The model has two strengths. – One is that it explains why a patient who intends to comply actually does not. – Secondly, the model is easily testable.
Rational non-adherence Sometimes the side effects of a treatment can be so devastating, that the patient decides, quite rationally, not to proceed with the treatment. Bulpitt (1988) medication used for the treatment of hypertension reduced the symptoms of depression and headache. However, the men taking the drug experienced increased sexual problems (difficulty with ejaculation and impotence).
Rational non-adherence Chapin (1980) suggested that 10% of admissions to a geriatric unit were the result of drug side effects. Most non-adherence in arthritis patients was owing to unintentional reasons (e.g. forgetting); the common intentional reasons were side effects and cost (Lorish et al, 1989).
Other useful concepts1. Behavioural explanations - habits, imitation (young smokers copying peers), reinforcement (short term treatment will provide this, but long term treatment would not).2. Defence mechanisms - e.g. smokers might use avoidance by avoiding information about the harmful effects of smoking. Also, they could use denial, pretending that smoking is harmless.
Other useful concepts3 Conformity - e.g. men acting hard in front of their mates, and therefore not complying with their doctors requests.4 Self-efficacy (believe they can do something about the problem) and locus of control (feel that they have some control over the illness).