1. Lecture 3: Health Psychology and Physical Illnesses I (Part 2)
Dr. Antoinette Lee
The University of Hong Kong

2. Adherence
Adherence: “adopting behaviors or treatments that health care providers advice”
Better term them compliance
Non-Adherence is a big challenge for healthcare professionals
Antoinette M. Lee, HKU
Master in Behavioral Health
Health Psychology Module, Spring 2005

3. Non-Adherence Includes Medication / Drug Non-drug treatment
errors of omission
taking of medicine for wrong reasons
errors in dosage
mistakes in timing
taking additional medication not prescribed by physician
total abandonment
Non-drug treatment
Lifestyle change
Keeping appointments
Monitoring
Antoinette M. Lee, HKU
Master in Behavioral Health
Health Psychology Module, Spring 2005

4. Non-adherence
23-45% of patients do not take their medications as prescribed by their physicians
Short-term antibiotic regimens: at least 1/3 non-adherence
Appointments for
Lifestyle changes (on one’s own): 50-80% non-adherence
Dropping out of lifestyle change programs: 20-80%
Antoinette M. Lee, HKU
Master in Behavioral Health
Health Psychology Module, Spring 2005

5. Non-Adherence McElnay et al. (1997) 15-63% among psychiatric patients
25-50% of general outpatients
less common among inpatients
Antoinette M. Lee, HKU
Master in Behavioral Health
Health Psychology Module, Spring 2005

6. Non-Adherence Davidson (1982) appointment-keeping - 50%
taking short-term medication - 60%-80%
taking long-term prophylaxis - 50%
taking long-term drug to cure a disorder - 50%
Antoinette M. Lee, HKU
Master in Behavioral Health
Health Psychology Module, Spring 2005

7. Methods of Assessing Adherence
A highly difficult task with a lot of potential pitfalls
May include:
Patient’s self-report
Family member’s report
Pill counts
Mechanical device to record time of opening a container
Urine test
Blood test
Observation (for in-patients)
Treatment outcome, relapse
Charting actual follow-up appointments kept
Are they taken in the correct amount, time, and manner?
Antoinette M. Lee, HKU
Master in Behavioral Health
Health Psychology Module, Spring 2005

8. Case in Point: Depression
Who are more likely to be non-adherent?
Those in difficult social circumstances
Those with mental disorders
Compliance management among
depressed patients a particularly
difficult task!!
Antoinette M. Lee, HKU
Master in Behavioral Health
Health Psychology Module, Spring 2005

9. Reasons for Non-Adherence
Poor rapport
Denial of illness or its severity
Poor knowledge
Forgetting
Complicated or inconvenient dosage regimen
Lengthy treatment regimen
Disruption to life
Intolerable side effects
Perceived adverse effects of medication
Adherence as product of “cost/risk – benefit analysis”
Antoinette M. Lee, HKU
Master in Behavioral Health
Health Psychology Module, Spring 2005

10. Reasons for Non-Adherence
Perceived lack of efficacy of treatment
Perceived self-efficacy
Esp. true for cases in which complex skill acquisition is needed
Poor access to treatment / barriers (e.g. cost)
“Creative / intelligent non-adherence”
Modifying or supplementing a treatment regimens
Fear of dependence
Resists psychiatric diagnosis
Improvement
Depression
Antoinette M. Lee, HKU
Master in Behavioral Health
Health Psychology Module, Spring 2005

11. Improving Compliance Doctor-Patient Relationship Good rapport Empathy
Holistic approach: focus on the person, not the symptoms
Professionalism
Therapeutic alliance
Constant follow-up
Invite patients to ask questions
Sensitive questioning
Third-party reference
Therapy tailoring
Fitting in to patient’s lifestyle, schedule, preferences etc.
Simplify / change dosing regimen; avoid polypharmacy if possible
Antoinette M. Lee, HKU
Master in Behavioral Health
Health Psychology Module, Spring 2005

12. Improving Adherence Cognitive Strategies
Explain
The illness: causes, severity, treatability
The drug’s mechanism of action
Regimen
Rationale for the regimen (e.g. antibiotic)
Interaction with other drugs and consequences
Side effects & support with dealing with side effects
Gauge expectations and worries (perceived barriers)
Elicit patient’s perceived negative effects of medication or lifestyle change
Adherence as product of cost-benefit analysis
Understand patient’s health beliefs and note discrepancies with clinician’s
More likely to choose /adhere to a treatment option when it is framed attractively (40% chance of surviving versus 60% chance of not surviving)
Antoinette M. Lee, HKU
Master in Behavioral Health
Health Psychology Module, Spring 2005

13. Improving Adherence Clear & simple instructions
Clear and patient explanation, repetition
Written
Ask patient to repeat
Demonstration of complex skills, followed by asking patient to perform the skill in front of you
On follow-up: ask patients about how they actually took their medication, what difficulties they encountered
Work out strategies to get around the problem with the patient
NEVER tell patients what the drug is not
Antoinette M. Lee, HKU
Master in Behavioral Health
Health Psychology Module, Spring 2005

14. Improving Adherence Behavioral Strategies
Reinforcements
Cues
Tying in with regular features of patient’s daily routines
Pill organizers
Enlisting the help of significant other
Antoinette M. Lee, HKU
Master in Behavioral Health
Health Psychology Module, Spring 2005