1. Health Psychology Adherence

2. Requirements Why we don’t Why we don’t Measuring Measuring Improving Improving Use the first 4 or last 3 studies Use the first 4 or last 3 studies

3. Background ADHERENCE ADHERENCE Adherence rates requiring medicine for long or short term illness = 60%. But if a diet or exercise/lifestyle change needed compliance is lower. Adherence rates requiring medicine for long or short term illness = 60%. But if a diet or exercise/lifestyle change needed compliance is lower. CUSTOMISING CUSTOMISING Follow advice reasonably closely but make an attempt to get it to fit with lifestyle Follow advice reasonably closely but make an attempt to get it to fit with lifestyle RATIONAL NON-ADHERENCE RATIONAL NON-ADHERENCE Choosing not to comply – may not have a belief in the benefits, treatment causes suffering, confusion, practical barriers (cost), is illness still there when medication isn’t Choosing not to comply – may not have a belief in the benefits, treatment causes suffering, confusion, practical barriers (cost), is illness still there when medication isn’t LOCUS OF CONTORL LOCUS OF CONTORL Personal choice or little influence over what is happening. More they feel in control more likely to adhere. Personal choice or little influence over what is happening. More they feel in control more likely to adhere. SELF-EFFICACY SELF-EFFICACY A belief they will be successful in what they do and given the means to be capable too. A belief they will be successful in what they do and given the means to be capable too. DOCTORS AS PATIENTS DOCTORS AS PATIENTS Shouldn’t self prescribe but 70% do. Shouldn’t treat family members – 80% do Shouldn’t self prescribe but 70% do. Shouldn’t treat family members – 80% do

4. Background 2 TYPES OF REQUEST TYPES OF REQUEST Short term adherence (3x a day for 3 weeks); lifestyle (eat more fruit); stop (stop smoking); long term regime (diabetic diet, renal dialysis) Short term adherence (3x a day for 3 weeks); lifestyle (eat more fruit); stop (stop smoking); long term regime (diabetic diet, renal dialysis) MEASUREMENT MEASUREMENT Self report – ask. Patients overestimate Self report – ask. Patients overestimate Therapy outcome – getting better. Other factors may affect Therapy outcome – getting better. Other factors may affect Health worker estimates – unreliable Health worker estimates – unreliable Pill count – how many thrown away? Random raid? Pill count – how many thrown away? Random raid? Mechanical method – devices on bottle; measure how many taken out, but not how many taken Mechanical method – devices on bottle; measure how many taken out, but not how many taken Biochemical test – blood/urine test Biochemical test – blood/urine test

5. Background 3 IMPROVING IMPROVING Old people have different understanding and can’t follow complex instructions Old people have different understanding and can’t follow complex instructions Containers are difficult Containers are difficult Large ranges of treatment increase side-effects Large ranges of treatment increase side-effects PRESENTATION PRESENTATION Simple verbal instructions Simple verbal instructions Specific not general Specific not general Smaller steps Smaller steps Key information emphasised Key information emphasised Simple written Simple written Repeat in own words Repeat in own words MEMORY MEMORY Structured/categorised information easier to remember Structured/categorised information easier to remember Primacy effect Primacy effect Repetition does not improve recall Repetition does not improve recall Some medical knowledge helps Some medical knowledge helps TECHNICALITIES TECHNICALITIES Baffle and intimidate Baffle and intimidate If not understood or recalled then unlikely to adhere If not understood or recalled then unlikely to adhere DOT DOT Direct observation of patient taking medication Direct observation of patient taking medication

6. 3 Short Summaries We don’t always do as we are told by health workers (or mothers). At first glance this appears to be lazy or even reckless, but careful closer consideration shows many health choices we make are a common-sense way of dealing with the many influences on us We don’t always do as we are told by health workers (or mothers). At first glance this appears to be lazy or even reckless, but careful closer consideration shows many health choices we make are a common-sense way of dealing with the many influences on us Measuring behaviour is difficult at the best of times. Measuring behaviour such as treatment adherence, often done in private, is even more difficult. The various methods used, however, probably give a fair idea of how much people follow medical advice. Measuring behaviour is difficult at the best of times. Measuring behaviour such as treatment adherence, often done in private, is even more difficult. The various methods used, however, probably give a fair idea of how much people follow medical advice. People can be encouraged to be more adherent through a variety of methods. The more successful ones include improving available information, watching people take the medicine, and threatening with prison. People can be encouraged to be more adherent through a variety of methods. The more successful ones include improving available information, watching people take the medicine, and threatening with prison.

7. Adherence – Study 1 Sethi et al Sethi et al Who Who 2003 2003 Drug adherence to antiviral therapy & resistance Drug adherence to antiviral therapy & resistance Correlation, longitudinal Correlation, longitudinal 195, 32-48yrs, HIV Moor clinic – restricted cluster (criteria met – drugs prescribed, low HIV load, no drug mutations, no viral failure) 195, 32-48yrs, HIV Moor clinic – restricted cluster (criteria met – drugs prescribed, low HIV load, no drug mutations, no viral failure) Paid & informed Paid & informed What What Visit following clinic appointments Visit following clinic appointments Cumulative adherence measured using formula (prescribed – missed / prescribed) and categorised Cumulative adherence measured using formula (prescribed – missed / prescribed) and categorised HIV load tested – independent, experienced, blind tester – if greater than 500 loads then resistance HIV load tested – independent, experienced, blind tester – if greater than 500 loads then resistance Results Results 14% developed resistance 14% developed resistance 66% no resistance; 19% not followed up (death, prison, discontinuation, attrition, transfer) 66% no resistance; 19% not followed up (death, prison, discontinuation, attrition, transfer) Cumulative adherence 70-89& shows significance with resistance to drugs. Outside this range no correlation with resistance. Bell shaped distribution of adherence and drug-resistance Cumulative adherence 70-89& shows significance with resistance to drugs. Outside this range no correlation with resistance. Bell shaped distribution of adherence and drug-resistance

8. Adherence – Study 2 Yung Yung Who Who 1998 1998 Age and knowledge and relationship with adherence Age and knowledge and relationship with adherence 56 men, 70 women, 50-82 years, diabetic, clinic, HK, cluster sample. Natural experiment 56 men, 70 women, 50-82 years, diabetic, clinic, HK, cluster sample. Natural experiment What What 7 weeks informed consent, interviewed by 1/3 pharmacy studnets under supervision ½ doctors. 7 weeks informed consent, interviewed by 1/3 pharmacy studnets under supervision ½ doctors. Data includes age, sex, duration of & treatment, attendance at classes, presence of complications, attacks, other conditions, blood glucose, renal, liver function tests. Data includes age, sex, duration of & treatment, attendance at classes, presence of complications, attacks, other conditions, blood glucose, renal, liver function tests. 2 validate questionnaires. 1 – knowledge of conditions and adherence – what is wrong with your blood glucose, what do the tablets d, meals, miss meal, too many, dizzy, card carried, attack, sweets, relatives. 2 – measure knowledge of symptoms of attack – yes, no, don’t know, list given 2 validate questionnaires. 1 – knowledge of conditions and adherence – what is wrong with your blood glucose, what do the tablets d, meals, miss meal, too many, dizzy, card carried, attack, sweets, relatives. 2 – measure knowledge of symptoms of attack – yes, no, don’t know, list given Read if illiterate/visually impaired, care not to ask leading questions Read if illiterate/visually impaired, care not to ask leading questions More correct answers = greater knowledge/adherence More correct answers = greater knowledge/adherence Results Results Significant decline in correct answers given to knowledge as age increased, but only to half of adherence questions. Significant decline in knowledge of symptoms with age (except tingling lips) Significant decline in correct answers given to knowledge as age increased, but only to half of adherence questions. Significant decline in knowledge of symptoms with age (except tingling lips) Previous experience of attack had no effect on knowledge Previous experience of attack had no effect on knowledge If never attended classes then scored lower on all variables (knowledge of diabetes, knowledge of attacks, adherence) If never attended classes then scored lower on all variables (knowledge of diabetes, knowledge of attacks, adherence) More recent attendance correlated higher scores More recent attendance correlated higher scores

9. Adherence – Study 3 Watt et al Watt et al Who Who 2003 2003 Funhaler – asthma made fun Funhaler – asthma made fun Experiment Experiment 10 boys, 22 girls, mean age 3.2y 10 boys, 22 girls, mean age 3.2y All prescribed drugs via inhaler All prescribed drugs via inhaler Informed consent from parents Informed consent from parents What What Standard inhaler in week 1. Funhaler week 2 (toys, spinner, whistle – distracts and reinforces correct delivery, doesn’t interfere, can be replaced if bored) Standard inhaler in week 1. Funhaler week 2 (toys, spinner, whistle – distracts and reinforces correct delivery, doesn’t interfere, can be replaced if bored) Adherence measured via parents questionnaire frequency and regularity of use Adherence measured via parents questionnaire frequency and regularity of use Results Results 27/32 completed questionnaires. 38% administered Funhaler more regularly, 60% more children took recommended cycles 27/32 completed questionnaires. 38% administered Funhaler more regularly, 60% more children took recommended cycles

10. Adherence – Study 4 Sharma Sharma Who Who 2003 2003 Adherence to food pyramid by ethnic groups Adherence to food pyramid by ethnic groups Natural experiment, 115000 people 45-75y, ethnic groups (American, Japanese American, Hawaiian) quota sample, informed consent Natural experiment, 115000 people 45-75y, ethnic groups (American, Japanese American, Hawaiian) quota sample, informed consent What What Questionnaire – food frequency questionnaire, standardised before use Questionnaire – food frequency questionnaire, standardised before use Self administered postal. Asks how often foodstuffs eaten over 3 days, covered 85% intake of fat, fibre, vitamin A, carotenoids, vitamin C, measured in servings and converted to calories. Traditional foods to ethnic groups covered even if nutritional value not relevant Self administered postal. Asks how often foodstuffs eaten over 3 days, covered 85% intake of fat, fibre, vitamin A, carotenoids, vitamin C, measured in servings and converted to calories. Traditional foods to ethnic groups covered even if nutritional value not relevant Results Results Data for each group compared to recommended intake. Little variation between ethnic groups and adherence – no one adhered more than any other group. If calorie intake below 1600 per day (regardless of ethnicity) then food groups missed out (usually dairy) 58% of time. If calorie intake above 2800 (no ethnicity associated) then 3x alcohol, more fat and added sugar Data for each group compared to recommended intake. Little variation between ethnic groups and adherence – no one adhered more than any other group. If calorie intake below 1600 per day (regardless of ethnicity) then food groups missed out (usually dairy) 58% of time. If calorie intake above 2800 (no ethnicity associated) then 3x alcohol, more fat and added sugar Between groups – Hawaiians had highest daily calorie intake and high BMI, ate most daily servings of food groups with exception of dairy. Japanese- Americans had low BMI but the men ate 2 more servings per day of grain than white men. Between groups – Hawaiians had highest daily calorie intake and high BMI, ate most daily servings of food groups with exception of dairy. Japanese- Americans had low BMI but the men ate 2 more servings per day of grain than white men.

11. Study 5 DiMatteo DiMatteo Who Who 2000 2000 Depression is risk factor for non-compliance Depression is risk factor for non-compliance 25 studies, 68-98, 12 about depression, 13 about anxiety 25 studies, 68-98, 12 about depression, 13 about anxiety What What Studies measure adherence and depression/anxiety but not being treated for depression/anxiety – reviewed results Studies measure adherence and depression/anxiety but not being treated for depression/anxiety – reviewed results Results Results No correlation between anxiety and non-adherence but strong correlation between depression and non-adherence No correlation between anxiety and non-adherence but strong correlation between depression and non-adherence Compared with non-depressed patients, depressed patients are 3x more likely to fail to adhere Compared with non-depressed patients, depressed patients are 3x more likely to fail to adhere

12. Study 6 Choo et al Choo et al Who Who 2001 2001 Risk factors for over-reporting adherence Risk factors for over-reporting adherence 286 (age 18-84, 50% female, 33% black, 67% graduate) on anti- hypertensive therapy 286 (age 18-84, 50% female, 33% black, 67% graduate) on anti- hypertensive therapy What What Baseline questionnaire – socio-economic status, medication, adherence, health beliefs, health status, social support. Baseline questionnaire – socio-economic status, medication, adherence, health beliefs, health status, social support. 3 months monitoring – adherence question – while using special bottle how many days in average week did you forget to take a pill? Actual adherence measured by electronic monitoring vial. Informed about purpose of electronic medication monitor 3 months monitoring – adherence question – while using special bottle how many days in average week did you forget to take a pill? Actual adherence measured by electronic monitoring vial. Informed about purpose of electronic medication monitor Results Results 21% admitted missing 1 or more days a week – but true figure 42%. Over-reporters tended to be from lower socio-economic background, lower health risk, and taking more than one daily dose 21% admitted missing 1 or more days a week – but true figure 42%. Over-reporters tended to be from lower socio-economic background, lower health risk, and taking more than one daily dose

13. Study 7 Lustman Lustman Who Who 2000 2000 Depression in diabetes Depression in diabetes Treat depression and see if adherence improves Treat depression and see if adherence improves 60 patients diabetic and major depression; advertisement 2 centres (screened out suicidal, bipolar, psychotic) 60 patients diabetic and major depression; advertisement 2 centres (screened out suicidal, bipolar, psychotic) What What Randomly assigned 2 groups. 1 – received antidepressive drug other placebo. Double blind. Over 8 weeks daily dose of antidepressive given and depression measured (2 known scales). Blood sugar monitored as a measure of adherence to medical regimen Randomly assigned 2 groups. 1 – received antidepressive drug other placebo. Double blind. Over 8 weeks daily dose of antidepressive given and depression measured (2 known scales). Blood sugar monitored as a measure of adherence to medical regimen If still depressed after 8 weeks referred for therapy If still depressed after 8 weeks referred for therapy Results Results Antidepressive patients less depressed and showed healthier blood sugar levels Antidepressive patients less depressed and showed healthier blood sugar levels

14. General Review Ethics Ethics Maintain confidentiality, informed consent, withdrawal rights, harm minimised etc Maintain confidentiality, informed consent, withdrawal rights, harm minimised etc Sharma & Watt some withdrawal seen Sharma & Watt some withdrawal seen All informed (parental in Watt) All informed (parental in Watt) Minimised harm – Funhaler designed to deliver drugs without affect Minimised harm – Funhaler designed to deliver drugs without affect Sethi & Yung, identified non-adherence factors but did nothing about it! Sethi & Yung, identified non-adherence factors but did nothing about it! Reliability/Validity Reliability/Validity Validity – measure what we think we are Validity – measure what we think we are Reliability – able to measure it consistently Reliability – able to measure it consistently Sethi – straightforward but face validity (no predictive validity) Sethi – straightforward but face validity (no predictive validity) Sampling Sampling Sharma – very large numbers involved, so ethnic groups well represented Sharma – very large numbers involved, so ethnic groups well represented Sethi – what if a different drug was used? Or a different medical condition Sethi – what if a different drug was used? Or a different medical condition May limit ability to generalise but also allows us to discuss factors May limit ability to generalise but also allows us to discuss factors Usefulness Usefulness Reveal why people do not adhere – therefore improve adherence Reveal why people do not adhere – therefore improve adherence Sharma – adherence to diet to develop programs for obesity Sharma – adherence to diet to develop programs for obesity Different groups require different approaches Different groups require different approaches Need to be fun – Watt Need to be fun – Watt Cognitive memory aids needed - Yung Cognitive memory aids needed - Yung

15. Questions Describe one study of why people do not adhere to medical advice (6) Describe one study of why people do not adhere to medical advice (6) Evaluate research into non-adherence to medical advice (10) Evaluate research into non-adherence to medical advice (10) Describe one way of measuring adherence/non-adherence (6) Describe one way of measuring adherence/non-adherence (6) Discuss validity of measures of adherence/non-adherence (10) Discuss validity of measures of adherence/non-adherence (10) Describe one way of improving adherence (6) Describe one way of improving adherence (6) Discuss problems of improving adherence (10) Discuss problems of improving adherence (10) Describe what psychologists have found out about why people do not follow medical advice (10) Describe what psychologists have found out about why people do not follow medical advice (10) Discuss the psychological evidence on the reasons why people do not follow medical advice (16) Discuss the psychological evidence on the reasons why people do not follow medical advice (16) Suggest one technique that could be used to encourage children to use their asthma inhalers more regularly. Give reasons for your answer (8) Suggest one technique that could be used to encourage children to use their asthma inhalers more regularly. Give reasons for your answer (8)