1. Adherence to Medical Advice 1. REASONS WHY PATIENTS DO NOT ADHERE 2. MEASURING ADHERENCE AND NON ADHERENCE 3. IMPROVING ADHERENCE

2. Reasons for non-adherence: cognitive rational non-adherence  Adherence is all about being conscientious in following medical advice.  This section looks specifically at following recommendations for taking medication  Starter - Work sheet

3. Why is adherence a problem?  Studies have suggested that about half of 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.

4. 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.

5. 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.

6. 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?

7. Why patients do not adhere!  Rational Choice Theory: people may not adhere for good reason: 1. They have reason to believe the treatment is not working 2. The side effects are unpleasant or effect the quality of their lives YouTube - Ambien Side Effects -- Research Findings YouTube - Ambien Side Effects -- Research Findings 3. There are practical barriers to the treatment such as cost or social difficulties (HBM) 4. They may want to check the illness is still there when they stop.

8. Rational non-adherence Bulpit (1988)  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!

9. Bulpitt: Rational Non Adherence  Aims  Aims: to review research on adherence in hypertensive patients.  Method  Method: Review article of range of research which identified problems with taking drugs for high blood pressure.  Review – Research was analysed to ID physical and physiological effects of new drug treatments on a person’s life (Including, hobbies, work, physical well being)  Findings  Findings: + Drug did reduce headaches and depression compared to old drug - Side effects: reduced circulation of blood (leading to erectile dysfunction, sleepiness, dizziness and problems with cognitive functioning. Affecting work and hobbies.

10.  Bulpitt: one study by Curb found that 8% of men stopped taking their medication due to sexual problems.  Research by the Medical Research Council found that 15% of patients had stopped taking the drug due to other side effects.  Conclusions  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 the benefits of the adherence.  Application?

11. Evaluation  Review – wealth of data (several countries) – holistic picture of effects of taking medication for hypertension  However, different methods – difficult to test reliability  Survey data – memory and social desirability  Debates:  Psychology as a science – rigorous picture: Incorporating vast amounts of qualitative data  Usefulness – Medical practitioners should be aware of the difficulties male patients will have in particular when taking these medications

12. Cognitive / Behavioural Theories of Adherence: Locus of Control – Rotter  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.

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

14. H/W  How can fear arousal be used as a method of health promotion? (10)

15. Measures of Non-adherence: Physiological Different methods of measuring adherence. Complete second part of table 1. Self-report – simply asking people - probably with questionnaires 2. Therapeutic outcome – have they got better? 3. Pill & bottle counts – raid the cupboard and see what is left! 4. Mechanical methods – how much medicine has been dispensed from the bottle? 5. Record number of repeat prescriptions 6. Biochemical tests - blood and urine Which of these methods are subjective/objective? How effective are each of these methods? 1. YouTube - Medication Adherence YouTube - Medication Adherence

16. 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.

17. Chung and Naya 2000 – Mechanical method  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.

18.  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 and number of pills left  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%.  Mechanical method effective method to measure adherence.  However – could patients have been influence by being told what was being measured?

19. Physiological methods  Lustman (2000)  Physical measures such as blood sugar levels can indicate adherence to a medical regime  Glycohaemoglobin (haemoglobin with glucose attached, GHb) will show levels of glucose in blood  Insulin – should keep levels normal  Therefore adherence can be measured by measuring Ghb

20. Lustman et al. (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 by measuring gylcemic control  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.

21. 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  Assessed for depression – psychometric tests  Daily does of medication for 8 wks  Patients and docs did not know to which group they had been assigned – avoidance of demand characteristics  Adherence to medical regime measured by GHb levels

22.  Findings:  Reduction in depression symptoms was significantly greater in patients treated with fluoxetine compared with those receiving the placebo.  Researchers were able to measure levels of GHb this 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.

23. Evaluation  Discuss  Psychometric and blood tests- Findings reliable  Small sample  Results taken after a short while (depressants take some time to work)  Rigorous design – restricts bias  Reductionist? (using alteration in brain chemistry through drugs rather than looking a whole lifestyle)  Useful – Evidence that adherence to a physical treatment could be affected by mental focus

24. Improving Adherence - Using behavioural methods  Complete the third part of the table  Many ways to improve adherence  Reduce costs (so that costs don’t outweigh benefits)  Study demographic variables of HBM (eg gender)  Look at perceptions of susceptibility and severity  LOC can influence adherence  Emphasising information and key details (Cowpe) and not using jargon (Ley, 1973)  Lewin (1992) info and instructions  Behavioural strategies – using reinforcement for correct adherence

25. Watt et al. (2003) Study used behaviourism and reinforcement for correct adherence thus a ‘funhaler’ with a whistle and spinner were used to reward children for using inhaler correctly. Funhaler: https://www.youtube.com/watch?v=6xhh8PowaKs Look up study in textbooks

26.  Aim: Improving adherence without compromising delivery. To see if using funhaler would improve children’s adherence to taking medication for asthma  Method: Field and quasi  2 conditions  Self report to measure adherence rates  Details: 32 Australian children (10 males, 22 females) 1.5-6 years  Diagnosed with asthma, prescribed drugs delivered by inhaler.  Parents gave informed consent

27.  Each child given ‘breath-a-tech’ to use for one week  Questionnaire for parents to complete  Second week children used the ‘funhaler’  Parent given matched questionnaire after the second week  Calculated the volume of air in the funhaler and thus the amount of Medication absorbed by the child

28.  Results:  38% more parents reported higher adherence in the children when using the funhaler  60% more children took the recommended four or more cycles per aerosol delivery when using the funhaler  Conclusions: Previous research: non adherence in children with asthma due to boredom, forgetfulness and apathy. Funhaler set out to remedy this by reinforcing correct usage with a toy.  This did improve the adherence to the medication. So by making the medical regime fun, the adherence, certainly in children, can be improved.

29.  Evaluation  Self report – social desirability  Validity – IV well defined and manipulated  Useful – implementing reinforcement can increase adherence  Generalisability – asthmatic children only (sal sample)  Reductionism – wider causes of adoption of health behaviours?  Construct validity – support for behavioural operant conditioning  Ethnocentric?  Snapshot?

30. 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.

31. Use the Behaviourist Approach to improve adherence 1. Feedback 1. Feedback and self monitoring the patient gets regular reports on the state of their health so reinforcing their adherence 2. Contingency contracts 2. Contingency contracts the patient negotiates a contract with the health worker concerning goals and rewards for achieving their goals 3. Modelling 3. Modelling the patients sees someone else who is successful in a support group or as a mentor etc. 4. Direct reinforcements or incentives 4. Direct reinforcements or incentives like being given money to continue on a programme or come off drugs 5. Punishment 5. 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.

32. 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  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.

33.  For example blood tests  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. Ethics

34. Social desirability bias and demand characteristics  For example286 patients were asked about compliance with a questionnaire whilst at the same time electronically monitoring their medication.  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%

35. Advantages of measuring and improving adherence  Usefulness  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  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.

36. Scientific nature of some tests reliable  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.

37. 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!

38. Cost benefits  HBM - 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.

39. Reductionism  It is important not to be reductionist when considering adherence  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.

40. 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.

41. 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 

42. 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

43. 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