Adherence to Medical Advice Reasons why patients do not adhere Measuring adherence and non adherence Improving adherence

Why is adherence a problem? Studies have suggested that about half the patients with chronic illnesses such as diabetes and hypertension (high blood pressure) are non-compliant with their regime. There is clearly a large financial cost for this in wasted drugs but also potentially in poor health outcomes.

A study by Sackett (1976) 50% of patients in America did not take prescribed medications according to the instructions and scheduled appointments for treatment were missed 20-50% of the time.

Taylor (1990) suggested that 93% of patients fail to adhere to some aspect of their treatment. Sarafino(1994) argued that people adhere reasonably closely about 78% of the time for short-term treatments but only 54% for chronic illness. A study by Becker (1972) looked at whether a prescribed anti-biotic was being taken halfway through a 10 day treatment programme in young children. Over half the mothers had stopped giving the medicine.

McKenny (1973) looked at hypertension He studied 50 patients for 7 months. After detection of high blood pressure only 50%-70% sought treatment He found that only 65% of pills were taken. Only 20% of the patients took as many as 90% of the pills. 33% of those who sought treatment dropped out. The question is why?

Why patients do not adhere! Rational Choice Theory: people may not adhere for good reason: They have reason to believe the treatment is not working The side effects are unpleasant or effect the quality of their lives YouTube - Ambien Side Effects -- Research Findings There are practical barriers to the treatment such as cost or social difficulties They may want to check the illness is still there when they stop.

Rational non-adherence* The patient may not believe what the doctor has suggested is in their best interest. Bulpit (1988) looked at treatments for hypertension and found that the side effects could include impotence and problems with ejaculation. Clearly for some men this would be seen as unacceptable!

Bulpitt: Rational Non Adherence* Aims: to review research on adherence in hypertensive patients. Method: Review article of range of research which identified problems with taking drugs for high blood pressure. Findings: anti hypertensive drugs have many side effects including sleepiness, dizziness, lack of sexual functioning. They also affect cognitive functioning and so work and hobbies may be curtailed.

Bulpitt reported that one study by Curb found that 8% of men stopped taking their medication due to sexual problems. He also reported that research by the Medical Research Council found that 15% of patients had stopped taking the drug due to other side effects. Conclusions of Bulpitt’s review were that the costs of taking some medication appear to outweigh the benefits for many patients, especially with problems such as high blood pressure which have no symptoms. Therefore some types of treatment (asymptomatic ones) may be more difficult to treat as people cannot feel thje benefits of the adherence.

Cognitive / Behavioural Theories of Adherence: Locus of Control – Rotter 1966

Cognitive / Behavioural Theories of Adherence: Locus of Control – Rotter 1966 The more a person feels in control the more likely they are to comply with their treatment programme. If we have an internal locus of control we are likely to have a higher self efficacy – more belief in what we do makes a difference.

Other theories to explain non/adherence: Psychoanalytic explanations include avoidance and denial of the problem

January 2012 Explain why people may not adhere to medical regimes. (10)

evaluation G R A V E Other e.g. debates

How can we measure adherence? What problems are there in each? Self-report – simply asking people - probably with questionnaires Therapeutic outcome – have they got better? Health worker estimates – ask the doctor Pill & bottle counts – raid the cupboard and see what is left! Mechanical methods – how much medicine has been dispensed from the bottle? Biochemical tests - blood and urine YouTube - Medication Adherence

Don’t ask Drs about adherence One of the least affective ways (Ley 1997) of measuring adherence is to ask doctors as they appear to vastly over estimate the extent to which their patients do adhere.

Chung and Naya 2000 * Was the first study to electronically assess compliance with an oral asthma medication. Aimed to see if patients did take their medication regularly and at the correct time of day. Taking regular asthma medication reduces attacks and prevents deaths. This study used an electronic Track Cap, an electronic device on the bottle top that recorded the date and time of the use of the medication.

57 Patients were told that adherence rates were being measured but not told about the Track Cap device and what it did. The treatment was taken twice a day 8 hours apart. The study was carried out over a 12 week period. Compliance was measured by the number of times the track cap was opened, the number of days that the track cap was opened at 8 hour apart intervals and the number of pills left at the end of the 12 week period. Over the period the track cap monitoring showed compliance was quite high at 71%. However the count of returned pills put the compliance rate even higher at 92%. ( However 10 patients dropped out of the study leaving the data being collected from only 47). These results show that compliance with adherence to a treatment of oral, twice a day asthma, maintenance medication is high.

Lustman (2000) Using physiological measure to assess adherence to medication and the treatment of depression in diabetics. Aim: to assess the effectiveness of fluoxetine as treatment for depression in patients with diabetes Method: lab experiment using a double blind technique and placebo control Participants: 60 patients who volunteered to take part (self-selected sample) Had either type 1 or type 2 diabetes and had been diagnosed with depression.

Patients re-assessed for depression Lustman (2000) Using physiological measure to assess adherence to medication and the treatment of depression in diabetics. Procedure: All patients screened for depression using the Becks Depression Inventory Randomly assigned to 2 groups Grp 1: given fluoxetine Grp 2: identical looking pill as placebo Daily does of medication for 8 wks Patients and docs did not know to which group they had been assigned – avoidance of demand characteristics Patients re-assessed for depression Assessed on their adherence to their medical regime (e.g. changing diet/administering insulin by injection) for controlling their diabetes through measuring blood sugar levels.

Lustman (2000) Using physiological measure to assess adherence to medication and the treatment of depression in diabetics. Findings: Reduction in depression symptoms was significantly greater in patients treated with fluoxetine compared with those receiving the placebo. Researchers were able to measure that patients with nearer normal blood sugar levels which indicated improved adherence to their regime. Conclusions: Measuring blood sugar levels in patients with diabetes indicates their level of adherence to medical regimes. Greater adherence shown by patients who were less depressed, suggesting that reduced depression may improve adherence in diabetic patients.

evaluation G R A V E Other e.g. debates

How can we improve adherence rates in patients E.g. Watt et al (2003) Funhaler spacer: improving adherence without compromising delivery See textbook for details on this study.

Make sure your patient is not depressed. Studies have shown that…..

Make sure your patient is not depressed. Studies have shown that often people who are ill are depressed or anxious and that treating the patient in a more holistic way (treating their psychological or emotional health as well as their physical health) can have a great effect.

Use the Behaviourist Approach to improve adherence

Use the Behaviourist Approach to improve adherence Feedback and self monitoring the patient gets regular reports on the state of their health so reinforcing their adherence Contingency contracts the patient negotiates a contract with the health worker concerning goals and rewards for achieving their goals Modelling the patients sees someone else who is successful in a support group or as a mentor etc. Direct reinforcements or incentives like being given money to continue on a programme or come off drugs Punishment In New York laws were changed so that people had to take the treatment (tuberculosis) and come to the clinic and be seen to take it or face compulsory admission to hospital.

Problems with Adherence and Measuring adherence Operationalising the variables of adherence is very difficult and different studies may do this in different ways making it difficult to compare studies. For example….

Problems with Adherence and Measuring adherence Operationalising the variables of adherence is very difficult and different studies may do this in different ways making it difficult to compare studies. For example is someone who just misses one dose non compliant ? If they just take it at the wrong time of day is that non compliance? If they take the wrong amount how much becomes non compliant – it will surely depend on the disease and on the medication.

Ethics of measuring adherence – for example: the best way would be to use scientific methods like blood tests but this is unethical. It is also unethical to observe people in their homes.

Social desirability bias and demand characteristics For example: 286 patients were asked about compliance with a questionnaire whilst at the same time electronically monitoring their medication. 21% admitted to missing a dose in the questionnaire but the electronic monitoring showed the true figure to be nearer 42%

Advantages of measuring and improving adherence Usefulness is a really important evaluating point for this section as obviously there are huge costs involved not only actual cost in terms of wasted medication but huge costs in terms of poor health and increased hospital admissions: for example it has been estimated that up to 70% of hospital admissions could be prevented if patients had been more adherent to previous health requests.

Scientific nature of some tests Blood and urine tests are highly reliable as they are scientific – Mechanical tracking devices like the track cap are also more reliable then the self report method.

Blood Tests Blood tests maybe highly unethical and also expensive to administer. You also would not be able to tell how often or how regularly the medicine had been taken as they may just have taken the medication before the blood tests!

Cost benefits Society has to weight up the costs and benefits of actions against non adherence. Some such as expensive pill counting measures, producing funhalers or blood tests may simply be too costly but others such as making sure written information is given to each patient would actually be cost effective in the long run.

Reductionism It is important not to be reductionist when considering adherence (that is not to consider the bigger picture). For example it is reductionist to assume that non adherence is as simple as making a rational choice. The reason for adherence may be a complex interaction between past positive or negatives experiences (behaviourism) and early trauma (psychodynamic) combined with biological side effects which may be very individual to one particular person.

Individual v situational The situational hypothesis would predict that adherence will differ in the same individual depending on the situation they are in: For example….

Individual v situational The situational hypothesis would predict that adherence will differ in the same individual depending on the situation they are in: For example when at home or on holiday it may be easy to take medication by leaving it in an obvious place that is noticed but this maybe more difficult if the person is at work.

Exam questions – 10 markers January 2010 Describe one way to measure non-adherence to medical advice. (10) HWK January 2012 Explain why people may not adhere to medical regimes. (10) (Rational Choice Theory – Completed) June 2013 How could adherence to medical regimes be improved? (10) TIMED CWK  

Group task In pairs, answer the following questions Please title your work ‘group classwork’: adherence to medical regimes 1. Discuss the difficulties of researching adherence to medical regimes. (15) DON’T FORGET TO ALWAYS BACK UP YOUR POINTS WITH EVIDENCE AND TRY TO ENSURE BALANCE IN YOUR ANSWER SOME POINTS TO CONSIDER: Research could impact professions Defensiveness from individuals Sensitive nature of the topic Ethics Demand characteristics Social desirability The methods themselves

Exam questions – 15 markers January 2010 Assess the reliability of research into non-adherence to medical advice. (15) January 2012 Discuss the difficulties of researching adherence to medical regimes. (15) – GROUP TASK June 2013 Discuss the usefulness of research into adherence to medical regimes. (15) - HWK