1. How can Health Psychology help?
TAKING THE TREATMENT
How can Health Psychology help?
John Weinman
Health Psychology Section
Psychology Dept. (at Guy’s)
IOP, Kings College London
Keynote address at NZ Psychology Society & NZCCP Conference
20-23 April 2012

2. “ Drugs don't work in patients who don't take them “
( C. Everett Koop, M.D. US Surgeon General , )

3. ADHERENCE / COMPLIANCE
The extent to which patients follow
medical treatment and advice
RESEARCH focuses on :-
the nature, patterning and levels of adherence
factors which explain / predict non-adherence
development / evaluation of interventions

4. The problem of non-adherence
WHO report on non-adherence
Estimated that over % medicines prescribed for long term illnesses are not taken as directed
Similar levels for psychol treatments - e.g . Attendance/homework for CBT
If treatment is evidence- based, then this represents a loss for patients and for the health care system
But, as a recent report by the WHO has identified between one third and a half of medicines prescribed for long-term illness are not taken as directed.
If we assume that the prescription was appropriate then this level of non-adherence is a concern for those, receiving, providing or funding care because it not only entails a waste of resources but also a missed opportunity for therapeutic benefit and health gain.

5. Risk of hospitalisation & non-adherence
Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Medical Care. 2005;43:

6. Health care cost of non-adherence

7. CAUSES OF NON-ADHERENCE
Common myths
Current evidence

8. Myth 1: Non-adherence is a feature of the disease
Non-adherence is not linked to type of disease
Low adherence rates are problematic
in most chronic diseases e.g.
HIV1
Cancer2
Heart disease3
Rheum. arthritis4
Diabetes5
Asthma6
4Hill et al. Ann Rheum Dis 2001;
5Glasgow et al. J Behav Med 1986;9:65–77.
6Cochrane et al. Respir Med 1999;93:763–769..
1Friedland, Williams. AIDS 1999;13(Suppl 1):S61–72.
2Lilleyman, Lennard. BMJ 1996;313:1219–1220.
3Horwitz et al. Lancet 1990;336:1002–1003.

9. Myth 2 Non-adherence is related to: Gender Educational experience
Intelligence
Marital status
Occupation / income
Ethnic background

10. Most patients will be non-adherent
Adherence Rates Vary
Between patients
Within the same patient
over time and
across treatments
More recent research has shown that adherecne rates vary between individuals but also within the same individual over time and between treatments.
Stable characteristics such as the nature of the disease and treatment or socio-demographic variables influence the adherecne behaviour of some patients more than others. This has led to a greater emphasis on understanding the interaction of the individual with the disease and treatment, rather than identifying the ‘stable’ characteristics of the “non-adherent patient”.
Thus it is much more accurate to view nonadherence as a behaviour which most people engage in some of the time, rather than a fixed personality trait
Most patients will be non-adherent
some of the time

11. Myth 3 Non-adherence is easily fixed by : - Providing information
Providing reminders
Being authoritative
Fear arousal

12. ADHERENCE INTERVENTIONS
Cochrane review:
Haynes et al (2008)
“Current methods of improving adherence are mostly complex and not very effective, so that the full benefits of treatment cannot be realized.
High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term disorders”

13. How can Health Psychology help?
Need to understand types and causes of non-adherence
Need to tailor interventions to take account of this
Develop & test theoretical models 13

14. TYPES OF NON-ADHERENCE

16. UNINTENTIONAL NON-ADHERENCE
RANGE OF POSSIBLE FACTORS :-
Poor HCP-Patient Communication
Low patient satisfaction and/or recall
Problems in planning/executive function
or prospective memory
Financial or other barriers

17. Beliefs influence unintentional non-adherence - forgetfulness 2
1 BCG Harris 2002; Conrad Soc Sci Med 1985;20:29–37; Ley 1988; Peterson Am J Health-Syst Ph 2003;60:657–65
2 Unni , Pat Edu Coun 2010 doi: /j.pec

19. INTENTIONAL NON-ADHERENCE
Patients know what to do & how to do it
BUT are reluctant to adhere because either :-
TREATMENT DOESN’T MAKE SENSE
WORRIES/CONCERNS ABOUT TREATMENT

20. Predictors of non-adherence : Overview of Evidence

21. What are the key beliefs influencing adherence to treatment?
Patients’ perceptions of illness
Patients’ perceptions of treatment

22. Core beliefs about Illness
IDENTITY Abstract label eg, hypertension; asthma; arthritis
Concrete symptoms that a person associates with the condition
CAUSAL BELIEFS Stress, environment, genetics, own behaviour, ageing etc
TIMELINE Perceived duration and profile eg, chronic, acute, cyclical
Health psychology studies have shown that when faced with a health threat (e.g. experiencing symptoms or receiving a medical diagnosis) people try to ‘make sense of it’ by answers five basic questions:
What is it?, How long will it last?, What caused it? How will it/has it affected me?, Can it be controlled or cured?
People form a mental model or representation of the illness which is made up of their answers to these questions and is strongly influenced by their experience of symptoms. They are more likely to follow health advice (e.g. to take medication) if it makes ‘common sense’ in the light of their own representation of the illness.
Lets look at it from the patients’ perspective. Before getting a diagnosis of hypertension , the average person’s experience of illness is an acute one. You feel unwell, you take action (e.g. take a medicine), the symptoms go away, you feel better, you stop taking the action. (Few people continue to take paracetamol after the headache has gone).
Research with hypertensive patients has shown that many develop a model of their illness, which differs from the medical view. In one study, many patients conceptualised their illness as an acute problem linked to stress (‘high-tension’). This influenced the action they took in dealing with it . They were significantly more likely to drop out of treatment or tended to use their anti-hypertensive medication intermittently, in response to perceived symptoms of stress such as headache or flushing, rather than taking it regularly as prescribed. This action, although mistaken from the medical view, is an understandable, logical response to mistaken beliefs about the nature of hypertension.
CONSEQUENCES Personal, economic, social
CURE / CONTROL Beliefs about the amenability to control or cure

24. ILLNESS PERCEPTION & treatment adherence
Some illness perceptions are associated with treatment adherence in some conditions :-
e.g. - causal beliefs predict adherence behaviour in post- MI (Weinman et al, 2000)
- timeline beliefs predict preventer medication adherence in asthma (Horne, Weinman, 2002)
- causal, timeline & control beliefs predict adherence to
CBT for Psychosis (Freeman et al, in press)
BUT – illness beliefs per se are not strong predictors of treatment adherence – need to consider more proximal predictors (ie patients’ beliefs re. treatment)

25. Illness
Treatment

26. GOODNESS OF FIT between illness reps and treatment recommendations
Patients evaluate the need for treatment in the light of their understanding of illness
But some treatments may not make sense :-
- exercises for back pain , balance disorder etc
- daily adherence to preventer medication in asthma
- smoking cessation in early cervical cancer
- phosphate binding medication in ESRD
CHALLENGE TO HP – to identify these situations and to assess treatment beliefs
-- develop interventions to increase adherence goodness of fit and increase motivation to adhere

27. TREATMENT BELIEFS:
What is the patient's perspective ?

28. Beliefs about Medicines Questionnaire
(BMQ)
SPECIFIC BELIEFS
about medicines prescribed for a particular illness
GENERAL BELIEFS
about medicines as a whole
This was questionnaire was cunningly titled the Beliefs and Medicines Questionnaire and it assesses beliefs about medicines prescribed for a particular illness (specific beliefs) as well as more general views about medicines as a class of treatment.

29. Necessity Concerns SPECIFIC BELIEFS Views about prescribed medication
Beliefs about necessity
of prescribed medication
for maintaining health
Concerns
Arising from beliefs about potential negative effects

30. Studies in asthma, CHD, cancer, renal dialysis, HIV/Aids, hypertension, diabetes
Horne et al (in press), Cooper et al (2002), Horne et al (2001), Horne & Weinman (2002), Horne (2000), Horne & Weinman (1999) Horne et al (1999), Horne (1988)
Low adherence
Doubts about
NECESSITY
Over the last decade studies involving over 4,000 people from several illness groups including current NHS priorities have shown that necessity beliefs and concerns are related to adherence.
Patients with stronger beliefs in the necessity of their medication were more adherent: those with stronger concerns were less adherent . The negative correlation between concerns and reported adherence suggests that patients may respond to fears about potential adverse effects by trying to minimise the perceived risks of medication by taking less. This is after all a logical response if one believes that the medication is necessary to control the illness yet is simultaneously concerned about potential adverse effects of taking it: one takes some but not all of the recommended dose.
Doubts about personal necessity and concerns about potential adverse effects are some of the key barriers to adherence.
Maybe pharmacists can prevent nonadherence with a simple message:
‘You really need this medicine and don’t worry it will be OK’
Unfortunately things are not that simple. To address these beliefs we need to know where they come from.
First let’s consider perceptions of need.
CONCERNS
about potential adverse effects

31. SUMMARY Patients’ beliefs about their illness and treatment
Influence adherence
Have an internal logic
Are influenced by symptoms
May differ from the ‘medical view’
May be based on mistaken beliefs/premises
May not be disclosed in consultation
Are not set in stone and can be changed

32. Implications for health care ?
Use the consultation to anticipate and plan
Interventions to :-
- improve goodness of fit
- improve understanding of illness and treatment

33. Using the consultation to facilitate informed adherence
Check patient’s understanding of treatment and , if necessary :-
Provide clear rationale for NECESSITY of treatment
Elicit and address CONCERNS
Agree practical plan for how, where and when to take treatment
Identify any possible barriers
NEEDS TRAINING OF HCPs – studies in progress

34. Interventions to improve adherence
Now a number of successful approaches which
are based on a good understanding of patients’ beliefs,
using different media, such as :-
text messaging
web-based interactive programmes
phone based support

35. Improving adherence : The example of Preventer medication in asthma

36. Asthma & patient self management
Common, chronic condition
Caused by inflammation of the airways
Characteristic symptoms include
Tightness in chest
Shortness of breath
Wheezing
Cough
Patient prescribed reliever medication & preventer medication
Picture of asthma patient 36

37. Non-adherence to asthma preventer medication
Non-adherence common
Adherence rates of between 10-50% frequently reported
Non-adherence costly
Increase in symptoms
Increase in healthcare utilisation
Reduction in quality of life
Reasons for non-adherence vary
Patient beliefs among factors most consistently associated with non-adherence to preventer medication
Beliefs about illness
Beliefs about medication 37

38. Relationships between illness and medication beliefs and self-reported adherence

39. Patient beliefs associated with non-adherence
Beliefs about illness
BIPQ (Broadbent, Petrie, Main & Weinman, 2006)
Low/high Identity
Short or episodic Timeline
Low/high Consequences
Low Coherence
Low Cure/Control
Beliefs about medication
BMQ (Horne, Weinman & Hankins, 1999)
Low Necessity
High Concerns

40. Profiling patients based on risk of non-adherence
Non-Adherent profile
Adherent profile
Timeline
Personal control
Treatment control
Identity
Consequences
Medication necessity
Medication concerns 40

41. British Journal of Health Psychology
Volume 17, Issue 1,
pages 74–84, February 2012

42. Method
212 patients aged recruited from medicine package inserts or heath websites - dx asthma (not COPD),
not taking preventer meds as prescribed
Baseline assessment
Normal care
Tailored Txt messages
18 weeks
Adherence assessments at 6,12,
18 weeks and 6 months

43. Targeted Texting Timeline Personal control Treatment control
Your preventer controls your asthma over the long term & stops attacks
Illness consequences
Your asthma is always there, even when you don’t have symptoms
Your preventer is safe to take every day
Medication necessity
Medication concerns

44. Preventer Adherence Levels
Mean compliance score
Compliance = puffs taken/puffs prescribed
Group difference p <.01

45. Percentage of patients reporting adherence at 80% or greater in control and intervention groups

46. Conclusions
A better understanding of patients perspectives of illness and treatment is key to understanding adherence
This approach offers a simple framework for identifying and addressing the key barriers to adherence to medication
Urgent need to develop coherent theory & theory-based interventions