This is Mark. He has decided to visit his doctor.

Oh doctor, I’ve got such horrible smelly feet! Please help me!

Oh, goodness, I suppose you’d better show me then.....

Blimey! You’ve got athlete’s foot, my boy. Well, here’s the deal......

Wash those feet daily (not necessarily in a bidet...)

Dry thoroughly in between those toes...

Cut toenails straight across.... Apply moisturiser... Please limit your wearing of fashion shoes; you need a good supportive shoe for good foot health...

Wear a verruca sock when swimming

Apply fungal cream twice daily and continue for two weeks after the infection has disappeared

You must apply the cream to the rash and also to the healthy 4 – 6 cm around the rash. Don’t forget!

TWO MONTHS LATER...

Well, how have you got on?

OH NO!! What do you mean, you didn’t adhere to my medical advice? Whyever not?

In pairs, complete the starter worksheet. You have about 10 minutes.

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. Where compliance means going against well established habits and going against strong motives (e.g. giving up smoking) compliance is even worse.

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.

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 FindingsYouTube - Ambien Side Effects -- Research Findings 3.There are practical barriers to the treatment such as cost or social difficulties 4.They may want to check the illness is still there when they stop.

 Aims  Aims: to review research on adherence in hypertensive male patients. Hypertension has no real short-term effects but in the long term can lead to heart disease and stroke.  Method  Method: Review article of range of research which identified problems with taking medication for high blood pressure.  Procedure  Procedure: Research analysed to identify the physical and psychological effects of drug treatment on person’s life. BULPITT ET AL (1988)

 Findings  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.  In one study Curb (1985) found that 8% discontinued due to sexual problems  GMC 15% stopped due to side effects  Conclusion:  Conclusion: When the costs of taking medication (the side effects) outweigh the benefits of treating a mainly asymptomatic problem such as raised BP, patient is less likely to adhere to treatment. BULPITT ET AL (1988)

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

HOW CAN WE MEASURE ADHERENCE? WHAT PROBLEMS ARE THERE IN EACH? 1.Self-report – simply asking people - probably with questionnaires 2.Therapeutic outcome – have they got better? 3.Health worker estimates – ask the doctor 4.Pill & bottle counts – raid the cupboard and see what is left! 5.Mechanical methods – how much medicine has been dispensed from the bottle? 6.Biochemical tests - blood and urine

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.

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 patietns 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

ESSAY PRACTICE Write a paragraph outlining how self-report as a measure of health adherence is reliabile. Include a ‘slapback’ Write a paragraph explaining why someone may or may not adhere to a medical regime – use evidence. Write a paragraph outlining ethical issues that might crop up when researching medical adherence.

WHAT IDEAS DID YOU COME UP WITH FOR IMPROVING ADHERENCE DURING THE FIRST LESSON?

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

WATT: IMPROVING ADHERENCE TO TAKING MEDICATION FOR ASTHMA Using reinforcement for following medical regimen improves adherence

‘WATT’ IS ASTHMA? When a person with asthma comes into contact with something that irritates their airways (an asthma trigger), the muscles around the walls of the airways tighten so that the airways become narrower and the lining of the airways becomes inflamed and starts to swell. These reactions cause the airways to become narrower and irritated - making it difficult to breath 5.4m people in the UK are currently receiving treatment for asthma 1.1m children in the UK are currently receiving treatment for asthma There is a person with asthma in 1 in 5 households in the UK

Funhaler has incentive toys (spinner and whistle) which function best when the child uses the deep breathing pattern that ensures the effective inhalation of the medication

WATT: IMPROVING ADHERENCE TO TAKING MEDICATION FOR ASTHMA Aim To see if using a Funhaler can improve children’s adherence to taking medication for asthma through reinforcement

WATT: IMPROVING ADHERENCE TO TAKING MEDICATION FOR ASTHMA Methodology A field experiment (also qualifies as quasi because it uses children with asthma) 2 conditions Uses self-report to measure adherence rates

WATT: IMPROVING ADHERENCE TO TAKING MEDICATION FOR ASTHMA Participants 32 Australian children (10M,22F)  Aged 1.5 to 6, mean age 3.2 All diagnosed with asthma + prescribed drugs delivered by pressurised metered dose inhaler (pDMI)  Parents gave informed consent

WATT: IMPROVING ADHERENCE TO TAKING MEDICATION FOR ASTHMA Design Repeated measures design  One week usng pMDI “Breath-a- tech”  One week using Funhaler

WATT: IMPROVING ADHERENCE TO TAKING MEDICATION FOR ASTHMA Procedure Child given Breath-a-Tech for 1 week and parents given questionnaire Child given Funhaler for 1 week and parents given matching questionnaire at end of 2 nd week

WATT: IMPROVING ADHERENCE TO TAKING MEDICATION FOR ASTHMA Findings 38% more parents were found to have medicated their children the previous day when using the Funhaler, compared to existing treatment

CONCLUSIONS Funhaler can be remedy for non-adherence caused by boredom, forgetfulness and apathy  These were reasons shown by previous research for non- adherence Adherence can improved by making it fun (positive reinforcement)

GROUP TASK In pairs, answer the following questions Please title your work ‘group classwork’: adherence to medical regimes 1. Explain why people may not adhere to medical regimes. (10) Write a model answer for this question. 2. 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

HOMEWORK Prepare for timed assessment – revise, no notes allowed.

HOMEWORK a) Describe one way to measure non-adherence to medical advice. (10) b) Discuss the usefulness of research into adherence to medical regimes. (15)

EXAM QUESTIONS – 10 MARKERS Describe one way to measure non-adherence to medical advice. (10) Explain why people may not adhere to medical regimes. (10) How could adherence to medical regimes be improved? (10)

EXAM QUESTIONS – 15 MARKERS Assess the reliability of research into non-adherence to medical advice. (15) Discuss the difficulties of researching adherence to medical regimes. (15) Discuss the usefulness of research into adherence to medical regimes. (15)