Health A2 Adherence to medical advice

Health A2 Adherence to medical advice: i) examples of and reasons why patients do not adhere; ii) measuring adherence/non-adherence; iii) improving adherence.

Task Make a list of 5 reasons to why people do not adhere to medical advice Rank them in order of importance

i) examples of and reasons why patients do not adhere Milgram looked at obedience and found that people obeyed authority. However, doctors have authority but many studies show lots of people not doing what they are told. It is difficult to know what word to use here – should it be obedience, or compliance or adherence? Which word would you use and why?

i) examples of and reasons why patients do not adhere Examples Kent & Dalgleish (1996) describe a study in which many parents of children who were prescribed a ten-day course of penicillin for a throat infection did not ensure that their children completed the treatment. The majority of the parents understood the diagnosis, and were familiar with the medicine. Even though 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 only 41% of the children were still being given the penicillin, and by day six only 29%.

i) examples of and reasons why patients do not adhere There are many studies to support this. Sackett (1976) found that 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.

i) examples of and reasons why patients do not adhere 33% of those who sought it dropped out. Sarafino(1994) argued that people adhere reasonably closely about 78% of the time for short-term treatments and 54% for chronic.

i) examples of and reasons why patients do not adhere Reasons These results seem to contradict Milgram’s study on obedience to authority which found that people are highly compliant. Perhaps the difference is that the situation of visiting and complying with a doctor's suggestions is very different. Patients have more knowledge and the doctor is not there when the treatment is actually being carried out.

i) examples of and reasons why patients do not adhere Health Belief Model: Perceived Threat a) evaluating the threat (perceived seriousness, perceived vulnerability), b) Cost benefit analysis.

i) examples of and reasons why patients do not adhere Kent & Dalgleish argued in their study that the key factor is not the doctor’s perception of how serious the matter is, rather it is the patient’s perception (or the patient’s mother’s perception). The antibiotics caused the symptoms disappear quickly, as a result the mother no longer perceived a threat, so discontinued the treatment

i) examples of and reasons why patients do not adhere Rational non-adherence: This concept provides evidence to support use of cost-benefit analysis. Some people might decide rationally that the treatment is not in their best interest. Task: Design a study for researching non-adherence

i) examples of and reasons why patients do not adhere Bulpit (1988) looked at treatments for hypertension and found that the side- effects could cause sexual problems. Some people might consider it a rational choice (or in cost-benefit terms, that the costs outweigh the benefits) not to take the drugs.

Bulpitt et al Key Study Aim: To review research on adherence to medical advice on hypertensive patients

Bulpitt et al Key Study Method: Review article of research identifying problems with taking drugs for high blood pressure

Bulpitt et al Key Study Procedure: Research analysed to identify the physical and psychological effects of drug treatments on a persons life

Bulpitt et al Key Study Findings: Many side effects from the medication Physical – problems with sleep dizziness, lack of sexual functioning and cognition (in particular problem solving)

Bulpitt et al Key Study These side effects will stop adherence even if the medical issue is serious! Cost benefit analysis Medical Council (1981) – 15% of patients do not continue taking medication due to side effects

Bulpitt et al Key Study What are the conclusions of this study and explain in detail Asymptomatic means carrying a disease/infection and not showing symptoms

i) examples of and reasons why patients do not adhere b) Theory of Planned Behaviour TPB has three components, attitude towards a behaviour, subjective norm, perceived behavioural control. It is the last one that is most relevant, especially with its link to concepts of self- efficacy and the locus of control.

i) examples of and reasons why patients do not adhere Payne & Walker (1996) provide evidence to support TPB a) low self esteem: P&W suggest that because people who have low self-esteem and low self-efficacy do not value their own ideas, they are more likely to value the doctors’ ideas and so adhere to medical advice.

i) examples of and reasons why patients do not adhere b) knowledge: the less the knowledge the more the adherence. c) Social support Kent & Dalgleish show that if family members are present at the consultation adherence is twice as high.

i) examples of and reasons why patients do not adhere d) Ley`s Model of Compliance (1981): understanding and memory. A new model which specifically addresses compliance is very simple. It says that compliance follows if patients are satisfied with the consultation process. Both satisfaction and compliance are affected by understanding and memory. For example, Kent & Dalgleish have shown that patients can forget up to 50% of their instructions within minutes of leaving the surgery.

i) examples of and reasons why patients do not adhere K&D also show that doctor-centred consultations have lower levels of adherence. This varies according to the degree of knowledge of the patient. It also conflicts with the Armstrong and Savage study from the practitioner-patient topic.

i) examples of and reasons why patients do not adhere But an evaluation of this could be that patients might be more satisfied subjectively by doctor-centred consultations, but they might, objectively, understand and remember better with a patient-centred style.

i) examples of and reasons why patients do not adhere Practical Application When visiting the doctor people are often anxious and at the same time they are getting lots of new information that is difficult to take in. Research has indicated that the way material is organised influences patients recall. Visual aids help. Over a three day period patients retain 10% of orally transmitted information, 20% visually transmitted and 65% information transmitted both ways.

Measuring Adherence/Non- Adherence

It is hard to measure adherence and non- adherence. Demand characteristics are likely to mean that people overstate their compliance. Adherence is also likely to vary according to the seriousness of the condition, whether the treatment is carried out at home.

Measuring Adherence/Non- Adherence There is a range of methods a) Physical measures: biochemical tests - blood and urine. Some psychologists also include patient improvement rates. However, this makes an assumption that adherence is a cause for improvement, and ignores many other factors. b) Self-report – questionnaires asking people what they have done.

Measuring Adherence/Non- Adherence c) Mechanical methods that measure how much medicine has been dispensed from the bottle. d) Observational methods: these are usually estimates by health-workers. Each of these methods has practical and ethical issues

Measuring Adherence/Non- Adherence A study by Chung & Naya (2000) into mechanical methods looked at asthma patients whose treatment involved taking pills twice a day, which was intended to reduce breathlessness. The medicine bottle had a specially designed lid (TrackCap) with an electronic device which recorded time and date each time it was opened. Patients were told that their adherence was being measured but they were not told about the bottle. Over a twelve week period compliance was measured at 71%.

Measuring Adherence/Non- Adherence Evaluation: ethical issues of deception, but perhaps that was justified by advantages of usefulness. Validity: measuring how often the bottle was opened is not the same as measuring whether the pills were taken.

Key study

Measuring Adherence/Non- Adherence Key Study: Lustman et al (2000) Aim Depression is prevalent in patients with diabetes and previous research suggests that it may be linked to non- adherence to the treatment regime. This study aims to see whether treating diabetic patients with the anti- depressant fluoxetine will improve their level of adherence.

Measuring Adherence/Non- Adherence Sample: The researchers advertised for participants within the Washington University Medical Center, and in the city of St Louis. Volunteers were excluded if they had a history of suicidal behaviour, bipolar mood disorder, any psychotic disorder, current alcohol or substance abuse disorder or who were currently on psychoactive medication. The remaining volunteers were screened for depression and the final sample consisted of 60 patients with diabetes and major depression (Type 1 and Type 2).

Measuring Adherence/Non- Adherence Method: Participants were randomly assigned to two groups; one receiving fluoxetine, and a control group receiving identical looking placebos. The design was double-blind, meaning that neither participants nor the researchers knew who had been given the fluoxetine. Over a period of eight weeks, the experimental group were given daily doses of fluoxetine, and the level of depression for all participants was measured using self- report methods (Becks Depression Inventory, BDI). Blood sugar levels were monitored to measure the patients’ adherence to their medical regime

Measuring Adherence/Non- Adherence Results: As expected, the participants who were given fluoxetine were significantly less depressed than the control group, they also showed healthier blood sugar levels.

iii) improving adherence. Conclusions: After only eight weeks of being treated with fluoxetine, diabetic patients tended to develop better control over their blood sugar levels, which was very probably as a result of better adherence to the treatment regime. It is, of course, possible that the fluoxetine had a direct effect on their diabetes, but this study provides strong evidence to suggest that one way of improving patient adherence is to reduce their level of depression.

iii) improving adherence. Evaluation of Lustman Effectiveness: Lustman’s study shows how effective drug therapy for the treatment of depression, and consequently for adherence. Usefulness: This study shows how adherence can be improved if depression is a part of the problem. What does it show about measures of adherence?

Measuring Adherence/Non- Adherence Evaluation of Measures a) Physical measures Although reliable and objective, may not be very effective in giving the full picture. Although a blood or urine test might be able to determine whether a particular drug is present, and in what quantity, it cannot always tell when the medication was taken, or how regularly it is taken. It is also time consuming and expensive to use this process in order to check adherence.

Measuring Adherence/Non- Adherence b) Self-report measures People tend to over-report their adherence. This may be deliberate for a particular reason such as rational non-adherence, but often patients report what they think the doctor wants to hear or what they wish they were able to achieve. Sometimes patients’ perception of what they are doing is inaccurate because they may not fully understand the method of treatment. This method of checking on patient adherence is therefore very subjective, ie lacking in validity, although it may be reliable.

Measuring Adherence/Non- Adherence c) Observation According to research by Ley (1997), one of the least effective ways is to ask the doctor. Doctors often overestimate the adherence. d) Ethics

Question Describe problems with measuring adherence to medical advice (15)

iii) improving adherence.

a) HBM Perceived threat Patients need to gain better understanding, which would give them more knowledge from which to make their cost-benefit analysis

iii) improving adherence. b) TPB Payne & Walker show that low self- esteem, external locus of control and little knowledge mean high adherence. This means a doctor-entered approach for low-self-esteem and less knowledgeable people. However, this does not apply to the better educated with an internal locus of control.

iii) improving adherence. Social factors Kent and Dalgleish show that if family members are present at the consultation then adherence is twice as high.

iii) improving adherence. Ley (1997): Understanding and memory (From Reasons work) Memory is difficult even at the best of times. When visiting the doctor people are often anxious and at the same time they are getting lots of new information, so it is even more difficult to take in.

iii) improving adherence. Ley found: Patients tended to remember best the first thing they were told (primacy effect). Repetition did not work – the doctor repeating the information made no difference. Specific information was recalled better than general (eg ‘take two tablets a day’ is easier to remember than ‘eat healthy food’.)

iii) improving adherence. Ley’s guidelines Information needs to be - verbal instructions clear and simple - written instructions clear and simple - specific rather than general - complicated programmes broken into simple steps - key information emphasised patients to repeat information in their own words

iii) improving adherence. Use written information. Ley & Morris 1984 looked at the effect of written information on medication and found that it increased knowledge in 90% studies and increased compliance in 60%, improved outcome in 57%.

iii) improving adherence. Behaviourism Operant conditioning suggests the use of reinforcement through reward. Approval from the doctor or from the social support network is a reward. With children (and adults too) treats like outings can be used. Classical conditioning would mean associating something with adherence. Some pill containers can be programmed to make a sound at the time the medicine should be taken. Telephoned reminders can also be used. Role models can be used.

iii) improving adherence. Watt et al 2003 Aim To see if using a Funhaler could improve children’s adherence to taking asthma medication.

iii) improving adherence. Watt et al 2003 Method A Field experiment with a repeated measures design (also natural experiment), each participant had one week using a normal pMDI inhaler and one week using the Funhaler. The participants were 32 Australian children (10 boys and 22 girls) with a mean age of 3.2 (between 1.5 and 6years old). They had all been diagnosed with Asthma and their parents had given informed consent.

iii) improving adherence. Watt et al 2003 Each child was given the standard inhaler for the first week and the funhaler (inhaler with incentive toys such as a spinner and whistle which work best when the child breathes deeply) for the second week. Parents completed a questionnaire at the end of the second week

iii) improving adherence. Watt et al 2003 Findings 38% more parents were found to have medicated their children the previous day using the funhaler compared to the standard inhaler.

iii) improving adherence. Watt et al 2003 Conclusions; Making a medical regimen fun can improve adherence in children. But does this work for adults?

Evaluate the study

Exam question Discuss the issues with researching adherence into medical advice (15)