CIE Psychology 9990: Adherence to Medical Advice

Pill Counting

Chung and Naya 2000

Biochemical Tests

Roth 1978

Riekart and Droter Procedure

- Asked to complete a series of questionnaires and interviews - The adolescent completed an adherence interview immediately after their appointment while the parents completed a demographic questionnaire - Afterwards the family was given a further questionnaire to be completed at home with a self-addressed return envelope - The researchers then evaluated the medical records of the families about the number of blood sugar test taken per day as a measure of their adherence to medical requests

Types of non-adherence

- Before treatment - During treatment - End of treatment

Ley 1988 Suggestions for Improving Adherence

- Doctors should consider their attitude and style of communication to improve adherence - The more information patients receive the more they feel they have been listened to, which will increase their subsequent adherence

End of treatment

- End the treatment earlier - Revert straight back to behaviours that were changed through the treatment

Yokley and Glenwick 1984 Evaluation

- Large sample= High ecological validity - No informed consent + Deception - Shows affective ways to increase adherence (Money) - Longitudinal study

Yokley and Glenwick 1984 Results

- Monetary Incentive had the most impact - Then the Increased Access group - Then Specific Prompt group

Chung and Naya 2000 Evaluation

- Objective way of measuring adherence - Easy to compare the levels of use to the prescribed dosage, but just because the pill is not in the container does not mean that the person has take it - Can't be used for non-drug treatments such as a new diet or attending physiotherapy

Sherman 2000 Results

- Physicians were only able to identify 49% of the patients who refilled less than 50% of their doses - Only identified 27% of those patients that used a certain drug excessively Conclusion: Physicians are unable to correctly identify patients with very poor adherence, checking refill history is a good way to verify adherence

Watt et al 2003 Evaluation

- Practical application= showed that adherence to medication is higher if the process of taking the drug is more enjoyable to children - Use of children= looked at how and why children adhere to medical requests and what interventions can be put into place to improve their engagement with drug taking

Sherman 2000 Evaluation

- Reliable way to measure adherence - But only tells the researcher that the drugs have been collected, can't determine if they are actually being consumed

Riekart and Droter Evaluation

- Self-reports are quick and useful (man measure more than just drug based prescriptions) - Proves that data from self-reports is highly subjective and not very reliable - Using children- Can be unethical and also have to think about demand characteristics as children are more likely to answer in a socially desirable way

Types of Medical Requests

- Short-term compliance with simple treatments (Take these tablets twice a day for 3 weeks) - Positive additions to lifestyle (Eat more fruits) - Stop certain behaviours (Stop smoking) - Longer-term treatment programs (Diabetic diet)

During treatment

- Taking more/less of the drug than instructed - Taking it at different time - Not completing the prescription - Only attending some follow up appointments

Chung and Naya 2000 Results

- When compliance was checked through TrackCap it was relatively high (71%) - But it was even higher for pill counting (92%) This could indicate that pill counting alone isn't a reliable measure as people might accidentally lose medication, remove multiple tablets at a time or might deliberately lose the tablets to

Sherman 2000 Procedure

116 kids with asthma - During clinical visit, doctors interviewed patients and caretakers and estimated their adherence to medication on a checklist - Nurse asked caretakers from which pharmacy they obtained and telephoned the pharmacy for the refill history (66 pharmacies in total) *Operationalised by calculating: Number of doses refilled divided by the number of doses prescribed over a period of up to 365 days

The Compliance Model

Becker suggested that these 5 variables combine to predict the likelihood of a patient taking the recommended health action prescribed by a doctor. - Motivations - Value of threat reduction - Probability of action reducing the threat - Cues to action - Modifying factors

Chung and Naya 2000 Procedure

57 patients with a history of asthma - An initial screening period of 2-3 weeks followed by a 12 week treatment period - Participants were instructed to take their medication 2x a day, 12 hours between each pill - At the beginning they were given 53 pills enough to last 3 weeks with one weeks supply to spare - Pills were in bottles that had a TrackCap on them which recorded the date and time whenever the bottle was opened - Patients were scheduled to return to the clinic every 3 weeks to refill the medicine - When they came for a refill the researchers counted the amount of leftover pills in the bottle and compared these results with the TrakCap *Adherence was operationalised = TrackCap showing pill being taken 2x a day, with at least an 8 hour interval between the pills

Yokley and Glenwick 1984 Experiment Groups

6 different groups: Mailed different types of prompts 1) No Contact control (Were not contacted at all) 2) Contact control (Received a phone call that informed them about the need to vaccinate their child) 3) General (Received prompt asking them to vaccinate their child) 4) Specific (Received a more personalized message containing details about the exact vaccines the child needs) 5) Increased access (Received the specific prompt plus a second page that informed about additional clinic hours at some hospitals that also offered free child care facilities) 6) Monetary Incentive (Received the specific prompt plus info about a lottery where they could win $25, $50, $100 if they vaccinated their child)

Riekart and Droter Subjects

94 families classified into 3 groups: Non-consenters- Declined to participate at recruitment Non-returners- Failed to return the self-reports Participants- At least one member turned in the questionnaire

The Health Belief Model

Attempts to predict when people will make rational health decisions. It assumes that the likelihood that individuals will follow medical advice depends directly on two assessments that they make: Evaluating the threat and a Cost-Benifit Analysis

Atreja et al 2005

Created SIMPLE to improve adherence: - Simplifying regimen characteristics - Imparting knowledge - Modifying patients beliefs - Patient and family communication - Leaving the bias (eg. not judging the patient's level of knowledge) - Evaluating the adherence

Bulpitt 1994 Aim

Examining the risks and benefits of drug treatment for hypertension in the elderly

Evaluating the Threat

Factors that influence a person perceived threat of illness: - Perceived seriousness - Perceived susceptibility - Cues to action - Demographic variables (income, levels of education, age, sex)

Yokley and Glenwick 1984 Procedure

Families with children 5 years or younger who needed one or more vaccine (Medium-sized Midwest city in America) - Each family was put into one of the 6 groups - Checked the impact of the different prompts over the following 12 weeks (how many families of each group went to the clinic for the vaccines)

Adherence

Following your medical practitioner's medical advice

Watt et al 2003

Funhaler- Asthma spacer device that incorporates incentive toys to a child's inhaler. IF the correct breathing technique is used, the child is rewarded by a fun whistle sound and a spinning toy within the inhaler

Watt et al 2003 Results

Looked at 32 children for 2 weeks, surveyed at random using a questionnaire -38% more parents were found to have medicated their children with the funhaler - 60% more children took the recommended four or more cycles when using the funhaler

Self-reports

Riekart and Droter 1999: Involves asking the patient if they are following their treatment program

Riekart and Droter Results

Out of the 94 families: - 14 non-consenters - 28 non-returners - 52 participants Results showed that families that returned the questionnaire had higher adherence interview scores and tested their blood sugar more frequently than those who did not return the questionnaire

Before treatment

Poor description of the treatment program, leading to a lack of awareness

Bulpitt 1994

Rational Non-adherence Believed that the public is "obsessed with risk" but rarely consider the benefits. One negative piece of media about a certain medication is enough for someone to rationalize a decision not to take that medication if it is ever superscribed

Ley 1988

Reviewed a selection of studies about GP and Hospital patients Found out that: - 28% of GP patients in the UK had low satisfaction ratings of treatment they received - 41% dissatisfaction from hospital patients Suggested that: - Patients were informed seekers and wanted to know more about their disorder and treatment - Dissatisfaction came from a lack of emotional support and a lack of information when prescribing drugs

Bulpitt 1994 Results

Reviewing two large trails • Risk: Increased gout (4/1000 patients), increased diabetes (9/1000 patients), dry mouth or diarrhea • Benefits: Reduction of "stroke events" by 40% and coronary events by 44% However, with the focus on risks over benefits, people may "rationally" decide to not take certain treatments because of the potential risks while ignoring the benifits

Repeat Prescriptions

Sherman 2000

Roth 1978

Stated that Biochemicals tests (blood and urine tests) can be used as a way to monitor adherence to medical treatment programmes. Empirical evidence has shown that adherence is higher with frequent urine monitoring + Reliable and objective way to measure adherence - Can't be used with diet, exercise or physiotherapy - Very time consuming and can be expensive

Becker and Rosenstock 1974

The Health Belief Model and The Compliance Model

Rational non-adherence

The act of deliberately not following medical advice due to the patient's personal, rational reasons

Sherman 2000 Aim

To determine whether a prescription refill history obtained by telephoning patients' pharmacies identifies poor adherence with asthma medication more frequently than physician assessment

Yokley and Glenwick 1984 Aim

To evaluate the relative impact of four conditions for motivating their children to be vaccinated

Riekart and Droter Aim

To examine the implications of non-participation in studies of treatment adherence among adolescents with chronic health conditions

Chung and Naya 2000 Aim

To measure adherence rates in oral asthma medication using TrackCap

The Funhaler

Watt et al 2003

Riekart and Droter Conclusion

When self-report measures are used, there is an association with lack of adherence and failure to respond to questionnaires. Needs to be take into account when looking at studies that use self-reports measures to collect data on adherence, as it may be distorted because they are only looking at those that completed the self-reports

Cost-Benefit Assessment

Whether the perceived benefits exceed the perceived drawbacks (finance, time, effort etc)

Money as an incentive

Yokley and Glenwick 1984

Types of influences on non-adherence

• Patient- Decides that there is no need for treatment or does not understand the treatment • Treatment program- Expensive, time consuming or hard • Health care provider- Does not stress the importance of the treatment, does not give adequate details