Adherence

Concordance

"Collaboration between patients and HCPs" - Time for discussion is needed - Tailor the treatment to the patient's lifestyle, not the other way around - More than adherence where people believe in what they are doing to a collaboration

National (US) Council on Patient Information and Education

- "Lack of medication adherence is America's other drug problem" - Poor medication adherence can lead to... 1. Unnecessary disease progression and complications 2. Reduced functional abilities and QOL & Lifestlye Behaviours 3. Increased use of expensive, specialized medical resources 4. Unneeded medication changes 5. The average length of stay due to medication nonadherence is 4.2 days in stroke patients

Quotes from Diabetes Educators

- "Yes, I know activity will help but I'm not interested" - If their diabetes is not well controlled, then their just not up to doing exercise - The fact that they have an exercise specialist connected with the program is huge - Just having that referral source helps promote exercise particularly with people who have several co-morbidities

Non-Adherence Reports

- 1 in 4 patients who suffer a heart attack do not bother filling the prescriptions for medications after leaving the hospital - Those who fail to take their meds have an up to 80% higher risk of dying in the year following the initial heart attack - "Not everyone understands the rationale for these medications ...we just aren't doing the education"

Components of Illness Representations

- 1. Identity: The name or label of a threat (e.g., sore throat/breast cancer) - 2. Timeline: The threat's believed time trajectory (e.g., acute/chronic/cyclical) - 3. Consequences: Perceptions of the consequence of a threat (minor or major) - 4. Cause: The threat's causal mechanism (e.g., hereditary,external,internal) - 5. Control/Cure: Can the threat be controlled? Will medical intervention help?... This can be related to personality - Those with HIGH in CONSCIENTIOUSNESS had stronger beliefs in effectiveness of diabetes treatments; NEUROTICISM is associated with beliefs about seriousness of diabetes but not the effectiveness of treatments.

Non-Adherence Blood Pressure

- Adherence to blood pressure medications is notoriously poor - About 30% have controlled BP... - Schedule (3 pills/day) hard to maintain - Hypertension is asymptomatic - people can't be aware of it - Forget - Away from home - Side effects: rashes/slow heart beat

Adherence

- Adherence: "Behave according to; follow in detail" The adherent person believes in what he or she is doing; following advice given by HCPs - Used to imply a more active/voluntary collaborative involvement of the patient in a mutually acceptable course of behaviour to produce a desired preventative or therapeutic result - Patients who are adherent are viewed as acting on a consensually agreed-upon plan that they may have had a part in designing, or at least as accepting the importance of performing the specific actions

Adherence to Lifestyle Recommendations

- As many as 75% of all people are unwilling or unable to stick to recommended healthy lifestyles (low-fat diet/avoid cigs/exercising) - Dietary regimes range from 30 to 70% compliance - Exercise programs 50% drop out within 6 months

Characteristics of Target Treatment

- Believe in its efficacy (will it work?) - Complexity (is it difficult?) - Convenience (does it interfere with other activities?) - Side effects - Is it long-term? - Does it require lifestyle change?

Factors that Influence Adherence

- Characteristics of the target behaviour (treatment) - Characteristics of the target person - Characteristics of the person giving advice - Normative influences 1. Subjective norms (e.g., social pressure) 2. Descriptive norms - (what do people like me do?)

Lowest Adherence Rates

- Chronic disorders - No immediate discomfort or risk is evident - Life-style changes are required - Prevention instead of symptom palliation or cure is desired outcome - For the chronically ill who do not see any immediate beneficial results from adhering to the treatment regimen - "Oh, it's a 'should' rather than a 'want' Note: PA adherence in Canada is 5%

Compliance

- Compliance: "The overt behaviour of one person that conforms to the wishes or the behaviour of others"... Includes: Obedience as a request; a compliant person does not necessarily believe in what he or she is doing - Refers to the extent that the patients obey their proscription/prescription/instruction given by their HCPs - Refers to the extent that the patient's behaviour coincides with proscription/prescription/instruction given by their HCPs - "Noncompliance" incorporates an evaluative concept that may imply a negative attitude toward the patient and presumes failure to comply is the patient's fault

Correcting Adherence Rates

- Education programs - 'Memory' gadgets? - Changing meds and regimes (make schedule less challenging) - Behavioural strategies (pair meds with toothbrushing) - Encourage physicians to (be more firm/update practices) - Encourage patients to (self-monitor for control-level awareness)(Ask physicians why control is poor) - Include patients in decision making and monitoring of treatment effectiveness

Source of Advice

- Expert (e.g, physician) Patient satisfaction linked to perception that physician understands problem, is sensitive, respectful and competent - Is source knowledgeable? Expert Knowledge (expertise in subject) vs. Personal Knowledge (respectful)

Communication

- Formal teaching of communication now integrated into medical school - Communication is two way Patients who are more active are better able to understand rational and recommend behaviour; In reality, patients tend to be passive

Non-Adherence Glaucoma

- Glaucoma patients who were told they would go blind if they didn't put drops in their eyes 3x a day - 42% adhered enough to produce the desired outcome - When the patients had become blind in one eye, adherence only improved from 42% to 58%

Social Influences

- Health-related behaviour is influenced by social context - Society (including mass media) can influence what is thought to be "normal" - Includes Advice from others - Organization of health systems (includes ease of access to services) - Having opportunity (e.g., time away from work) - Consultation not interfering with other activities (e.g., having time)

HCP Contributions

- Provide information on risk - Link target behaviour to desired outcome - Explain how to do the behaviour (forgotten frequently) - Keep prescriptions simple - Use persuasion techniques to convince target person that: 1. They need to do it 2. They can do it 3. That it won't interfere with other valued tasks - Work with the person to examine solutions to barriers

Who Gets Advice?

- Public health campaigns Everyone who notices; Principles of ELM apply here - Face-to-face advice People who ask for it; more personal characteristics, relationship characteristics, and characteristics of question (or problem) apply here Note: if HCP has general dislike to the type of person who comes and asks for help; may have reduced likelihood of coming back due to negative affect

Characteristics of the Target Person

- Social Support (Do they live alone?) - SES (nature of social environment - norms) - Beliefs about symptoms & treatment (how do they interpret symptoms?) - Conscientiousness increases; Pessismism decreases adherence (Personality) - Stress levels - Job and other life responsibilities

What Influences Adherence

- Symptoms 1. Persistence 2. perceived as serious 3. Perceived as curable 4. Interferes with other goals/activities - Treatments 1. Perceived to be effective 2. Don't interfere with other goal or activities 3. Not complex 4. Short-term

Frequencies

- The rate of non-compliance with medical or health advice is approximately 50% - At least 38% of patients do not follow short-term treatment plans (e.g., completing a prescription for medication) - As many as 43% do not adhere to recommendations for long-term treatment (e.g., hypertensive medication)

Adherence to Diabetic Regimen

- Type 1 vs. Type II diabetics... no difference in adherence - Dietary Non-Adherence situational factors of eating out and inappropriate offers from others - Exercise Nonadherence Negative physical reactions (sore/sick)

Summary

- Understanding how illness is represented for a person is important - Large numbers of people do not follow medical or lifestyle prescriptions - People need to believe in the treatment and it needs to fit with their needs - Communication is key

Seeking Health Help

- What about seeking help? - Only about 1/3 of people with 'symptoms' seek advice from HCP (health care professional) - Problems with.... 1. People who need care not consulting (unworried and unwell) 2. people who don't need care are consulting (worrying well) Note: Understand social norms vs. Subjective norms (TPB)

Example of Illness Representation

1. A sore throat - Labelled as the beginning symptoms of a cold (label) - This label determines that it is an acute condition (timeline), with minor consequences - It can be cured (control/cure) - Taken together; these attributes of the illness representation lead to common sense health behaviours (e.g., rest,fluids) - The emotional reactions are likely not large (e.g., annoyance) but some may worry that the cold is the start of something more serious (illness coherence)

Outcomes of Effective Communication

1. Increased patient satisfaction 2. Increased patient participation (more questions asked) 3. Increased accuracy of patient recall (greater sense of control from the patients) 4. Greater sense of control in patients

Example of Illness Representation

2. Lump in breast - The first thought may be "cancer" (label) - The cancer label will trigger thoughts about potentially life-threatening consequences, prolonged treatment (timeline) - An intense emotional reaction of anxiety and fear is likely triggered, Cancer-related thoughts are sometimes considered "hot cognitions" because illness representations an emotional responses are fused

Who Gives Advice?

Health Professionals... - Physicians - Nurses - Physiotherapists/Occupational therapists - Dentists - Kinesiologists - etc.. These people have Social Influence via... 1. Authority 2. Expertise 3. Sometimes relationship

Why Low Adherence?

Lifestyle Factors: - Environmental factors (e.g., poor housing) - Resource limitations - Occupational limitations - Lack of awareness of consequences Sociodemographic Factors - Age/Gender/Smoking/Drinking/Drugs - Lack of social support

Why Low Adherence?

Patient Factors: - Lack of knowledge - "carbohydrate is a big word, and a lot of people think in terms of sugar" - Lack of motivation - Lack of self-esteem - Beliefs and attitudes (cultural or religious backgrounds) e.g., Modern Medicine is ineffective (bullshit measles outbreak) e.g., Poor relationship with physician e.g., Perception of the severity of their illness

Non-Adherence to Prescription

Patient may... - fail to take the medication - take the wrong amount of medication - take the medication at the wrong time - discontinue the medication before the prescribed recommendation was complete

Why Low Adherence?

Psychosocial Factors - Depression/Anxiety: "a lot of times people with diabetes just want to have a vacation from that disease" - Lack of interest/time - Cost - Fear (side effects of insulin shots, Vulnerability?) - Dependency on others - Denial - Previous poor experience