Why patients do not adhere to medical advice.

Health Psychology

Compliance  Adherence  Concordance – Degree to which the patient carries out the behaviours the physician recommends (e.g., taking medication).

Extent of non-adherence problem  Difficulties with assessing it: – Many different kinds of medical advice to which one could adhere – Can violate advice in many different ways – Difficult to know if patient complied (50/50 chance that the physician’s judgment of the patient’s adherence is accurate).

Adherence     60% of patients may not be adhering to long-term treatment regimen 1-2 years later even in cardiac patients medication adherence over time is poor (i.e., 40% nonadherent 3 years later) Good predictor of long-term adherence is adherence at entry Distribution of adherence is tri-modal

1/3 Distribution of Adherence

Adherent Partial Adherent Non-adherent

1/3 1/3

Measuring Adherence in Clinical Practice  Physician impression overestimates patient adherence by about 50% (Caron, 1985).

 Electronic monitors of pills taken are impractical in routine clinical practice.

 Bio-chemical measures also have limitations  Self-report methods are good at detecting those who admit to adherence difficulties but will miss classify about 50% patients who deny problems or who are unaware of a problem.

Forms of Non-Adherence     Forgetting a dose Deliberately skipped doses Occasional day or even week off therapy Stopped therapy

Patients’ Reasons for Not Adhering          Forgetfulness (e.g., restaurant, trip) Financial (wait until pay day, take 1/2 dose to delay renewing prescription) Feeling sick Feel well (rare reason) Lazy about going to the drug store Too busy - forget Life events, stress (e.g., death in family) Don’t believe in the treatment Confused about dosage

Rational Reasons for Non adherence  Have reason to believe the treatment isn’t working  Feel that side-effects are not worth the benefits of treatment  Don’t have enough money to pay for treatment  Want to see if the illness is still there when they stop the treatment

Non-adherence: Characteristics of the regimen  Complex regimens have low adherence  Adherence decreases with duration of the regimen  Expense decreases adherence

Non-adherence: Cognitive Emotional Factors  Patients forget much of what the doctor tells them  Instruction and advice are forgotten more readily than other kinds of information  The more patient is told, the higher the likelihood of forgetting more.

 Patients remember what they are told first and what they think is most important.

Non-adherence: Cognitive Emotional Factors  More intelligent patients do not remember more than less intelligent patients  Older patients remember as much as younger patients  Moderately anxious recall more than low or high anxious patients  The more medical knowledge the patient has, the more he/she will remember.

Non-Adherence: Psychosocial Factors     Social support Personality - Dispositional Attitudes Affective State Knowledge and attitudes

Non-Adherence: Knowledge/Beliefs    Lack of knowledge Denial or trivialization Perceived invulnerability

Necessary but not sufficient

Non- Adherence - Behaviour    Early adherence, e.g., within first month of initiating therapy is an excellent predictor of later adherence, even 7 years later (Dunbar & Knoke, 1986) The more similar the predictor behaviour to the predicted behaviour, the higher the correlation.

Generally, little evidence for a health-oriented behaviour pattern.

Whey don’t people adhere?

 Did not understand the treatment regime (inadequate or non-existent instructions)  Forget  Side effects  Lack of commitment  Travel away from home  Depression  Feel better – did not see need for completion

Why do people fail to take medicines properly?

Non-adherence leads to •ineffective treatment •Additional health care expenditure •Anti-biotic resistance

How can services can help adherence?

      Spend time explaining the importance of adherence and help them to choose strategies that can help them to adhere More appropriate drug regimes (e.g. shorter times for completion of treatment) More acceptable presentation e.g. sugar coated anti-malarials, syrups etc.

Suitable packaging – blister packaging – lay-out Instructions with the packaging - simple words/pictures Involve partners so they can remind their partners

Medicine labelling/packaging

Used to explain

Dose, timing, side effects, things to avoid while taking medicines

Communication depends on:

Size/clarity of letters Language and complexity of words Literacy of audience and familiarity with medical terms Quality/comprehensibility of pictures and picture symbols e.g. sun/moon for time of day

Increasing Patient Adherence  Use clear (jargon free) sentences  Repeat key information  Recruit sources of support  Tailoring the regimen  Providing prompts and reminders  Self-monitoring  Behavioural contracting

Strategies that people can use to remember doses  Integrate regimes into daily routines  Have a checklist for recording doses taken  Count out daily doses as week at a time  Use a pill box, alarm or daily planner

Examples of methods methods used to encourage adherance      Leaflets, instructions Blister packaging A programme in South Africa used text messaging to remind people to take their tuberculosis medicines Visual aids like calendars Poster warning dangers of combining drugs and alcohol (Nicaragua)

Poster put up on the walls of clinics in UK to prevent unnecessary use of antibiotics

Extent of problem  Taylor (1990) 93% of patients fail to adhere to some aspect of their treatment.

Extent of problem

 Sarafino(1994) People adhere to treatment regimes reasonably closely 78% of the time.

 Sarafino found the average adherence rates for taking medicine to prevent illness is 60% for short and long term regimes.  Compliance to change one's diet or to give up smoking is variable and low.

Extent of problem  Compliance with chemotherapy is very high among adults with estimates of better than 90 percent of patients complying with the treatment.

Extent of problem

 Non compliance takes many forms. Some patients do not keep appointments; others do not follow advice.  Many patients fail to collect their prescriptions, discontinue medication early, fail to change their daily routine, and miss follow-up appointments (Sackett and Hayes, 1976).

Kent and Dalgleish (1996)

 Kent and Dalgleish (1996) describe a study in which many parents of children who were prescribed a ten-day course of penicillin for a streptococcal infection did not ensure that their children completed the treatment.

 The majority of the parents understood the diagnosis, were familiar with the medicine and knew how to obtain it.

Kent and Dalgleish (1996)  Despite the fact that the medication was free, the doctors were aware of the study and the families knew they would be followed up, by day three of the treatment 41% of the children were still being given the penicillin, and by day six only 29% were being given it.

(Ley, 1997).

 The costs associated with non-adherence can be high.  The illness may be prolonged in the patient and he or she may need extra visits to the doctor.  These are not the only costs, however, as the person may have a longer recovery period, might need more time off work or even require a stay in hospital.

(Ley, 1997).

 Non-adherence may lead to as much as 10%—20% of patients needing a second prescription, 5%—10% visiting their doctor for a second time, the same number needing extra days off work, and about 0.25 %—1% needing hospitalisation (Ley, 1997).

Methodological problem  Percentages are overestimated because patients who tend to volunteer for these studies would be more likely to be compliant.

Methodological problem  Patients often lie about their level of adherence, so as to present a good impression of themselves.

 It has been reported in the press that those patients who smoke may be afforded a low level of priority, when they are in need of a transplant.

 Patients might lie about their smoking, to avoid such discrimination.

Why patients do and don't adhere to advice

 Patients are less likely to change habits than heed medical advice to take medicine (Haynes, 1976).

Why patients do and don't adhere to advice

 Patients who view their illness as severe are more likely to comply (Becker & Rosenstock, 1984).

 Notice it is how the patient views the seriousness of the illness, not what the physician thinks!

Why patients do and don't adhere to advice

 Doctors tend to blame their patients for non adherence, attributing their behaviour to characteristics of their patients (mental capacity or personality traits) - Davis (1966).

Why patients do and don't adhere to advice

 Research has shown that it is not the patient's personality that predicts non adherence, but a combination of factors arising out of the doctor - patient relationship (e.g. Ley 1982).  Factors such as age and gender are predictive of compliance, depending upon what instructions are to be complied with.

Classic experiments - Milgram (1963) and Asch (1955.

 Milgram's experiment demonstrated that ordinary people will obey authority figures, to the extent that they would administer potentially lethal 'electric shocks' to a mild mannered victim.

 Asch's experiment demonstrated that people will agree with others even though it is obvious others are wrong.

(Haynes 1976).

 If medication is prescribed over a long time, it's more likely to be discontinued early (Haynes 1976).

Patient’s Report Doctor businesslike Doctor friendly but not businesslike High satisfaction with consultation Moderate satisfaction with consultation Moderate dissatisfaction with consultation High dissatisfaction with consultation % Compliant 31 46 53 43 32 17

Types of request

 requests for short-term compliance with simple treatments  requests for positive additions to lifestyle  requests to stop certain behaviours  requests for long-term treatment regimes

Ley model of patient compliance (1989).

Patient satisfaction  Ley (1988) reviews 21 studies of hospital patients and found that 28% of general practice patients in the UK were dissatisfied with the treatment they received.  Dissatisfaction amongst hospital patients was even higher with 41 per cent dissatisfied with their treatment.

Patient satisfaction  The dissatisfaction stemmed from affective aspects of the consultation (e.g. lack of emotional support and understanding), behavioural aspects (e.g. prescribing, adequate explanations) and competence (e.g. appropriateness of the referral, diagnosis).

Patient satisfaction  It was found that patients were "information seekers" (i.e. wanted to know as much information is possible about their condition), rather than "information blunters" (i.e. did not want to know the true seriousness of their condition).

Patient satisfaction  Over 85% of cancer patients wanted all information about diagnosis, treatment and prognosis (the chances of treatment being successful) (Reynolds et al., 1981).

Patient satisfaction  60 to 98% of terminally ill patients wanted to know their bad news (Veatch, 1978).

Patient satisfaction  Older research had found that a small but significant group did not want to be given the truth for cancer and heart disease (Kubler-Ross, 1969).  These findings could be due, in part, to the attitudes that prevailed during the late Sixties.  Research suggests that attitudes have changed since then.

TESTING A THEORY PATIENT SATISFACTION

A study to examine the effects of a general practitioner's consulting style on patient satisfaction (Savage and Armstrong 1990).

Methodology

 Subjects  The study was undertaken in group practices in an inner city area of London.

 Four patients from each surgery for one doctor, over four months were randomly selected for the study.

Methodology

 Patients were selected if they were aged 16 75, did not have a life-threatening condition, if they were not attending for administrative/preventative reasons, and if the GP involved considered that they would not be upset by the project.

Methodology

 Overall, 359 patient were invited to take part in the study and a total of 200 patients completed all assessments and were included in the data analysis.

Design

 The study involved a randomised controlled design with two conditions: (1) sharing consulting style and (2) directive consulting style.  Patients were randomly allocated to one condition and received a consultation with the GP involving the appropriate consulting style.

Procedure

 A set of cards was designed to randomly allocate each patient to a condition.

 When a patient entered the consulting room they were greeted and asked to describe their problem.

 When this was completed, the GP turned over a card to determine the appropriate style of consultation.

Procedure

 Advice and treatment were then given by the GP in that style.

 For example, the doctor's judgement on the consultation could have been either 'This is a serious problem/I don't think this is a serious problem' (a directive style) or 'Why do you think this has happened?' (a sharing style).



Procedure

 For the diagnosis, the doctor could either say 'You are suffering from. ..' (a directive style) or 'What do you think is wrong?' (a sharing style).  For the treatment advice the doctor could either say 'It is essential that you take this medicine' (a directive style) or 'What were you hoping I would be able to do?' (a sharing style).



Procedure

 Each consultation was recorded and assessed by an independent assessor to check that the consulting style used was in accordance with that selected.

Measures

 All subjects were asked to complete a questionnaire immediately after each consultation and one week later.  This contained questions about the patient's satisfaction with the consultation in terms of the following factors:

Measures



The doctor's understanding of the problem.

This was measured by items such as 'I perceived the general practitioner to have a complete understanding' .



The adequacy of the explanation of the problem.

This was measured by items such as 'I received an excellent explanation'.

Measures



Feeling helped.

This was measured by the statements 'I felt greatly helped' and 'I felt much better'.

 The results were analysed to evaluate differences in aspects of patient satisfaction between those patients who had received a directive versus a sharing consulting style.

Measures

 In addition, this difference was also examined in relation to patient characteristics (whether the patient had a physical problem, whether they received a prescription, had any tests and were infrequent attenders).

Patient Satisfaction

 The results showed that although all subjects reported high levels of satisfaction immediately after the consultation in terms of doctor's understanding, explanation and being helped, this was higher in those subjects who had received a directive style in their consultation.

Patient Satisfaction

 In addition, this difference was also found after one week.

 When the results were analysed to examine the role of patient characteristics on satisfaction, the results indicated that the directive style produced higher levels of satisfaction in those patients who rarely attended the surgery, had a physical problem, did not receive tests and received a prescription.

Patient understanding  Boyle (1970) asked patients to define a range of different illnesses and found the following:

Boyle (1970)

Illness to be defined

Arthritis Bronchitis Jaundice Palpitations

% correct

85 80 77 52

Roth (1979)

  Roth (1979) found that although patients understood that smoking is causally related to lung cancer, 50% thought that lung cancer caused by smoking had a good prognosis for recovery. It was also found that 13% of patients thought that hypertension could be cured by treatment when it can only be managed.

Patient recall

 Bain (1977) tested recall of a sample of patients who attended a GP practice. The following was found:

Instruction to be recalled The name of the prescribed drug Frequency of dose % unable to recall 37 23 Duration of treatment 25

Crichton et al. (1978)

 Crichton et al. (1978) found that 22% of patients had forgotten their advised treatment regimes after visiting their GPs.

Ley (1989)

  Ley (1989) found that the following factors increased recall of information:  Lowering of anxiety  Increased medical knowledge  Higher intellectual level (but see below)  Importance and frequency of statements  Primacy effects Age has no effect on recall success.

(DiMatteo & DiNicola 1982).

 Cognitive and emotional factors in patients' recall of information (DiMatteo & DiNicola 1982).

1.

Patients forget much of what is told to them 2.

Instructions and advice are more likely to be forgotten than other information 3.

The more a patient is told the greater the proportion a patient will forget 4.

Patients remember a) what they are told first and b) what they consider to be important 5.

Prior medical knowledge aids recall.

(DiMatteo & DiNicola 1982).

1.

2.

3.

Intelligence is not a factor (but see above) Age is not a factor Moderately anxious patients recall more than highly anxious patients

Homedes (1991)

 200 variables affect compliance.  Characteristics of the patient  Characteristics of the treatment regime  Features of the disease  The relationship between the health care provider and the patient  The clinical setting.

Becker and Rosenstock (1984) 1.

Evaluating the threat.

 Seriousness and vulnerability are taken into account.

 Being overweight would make you more vulnerable to a heart attack.

 A heart attack is serious.

 The patients relative youth would mean he or she is less vulnerable.

 And so on.

Becker and Rosenstock (1984)  Seriousness and vulnerability being high would be a good predictor of the likelihood of action.

 However, there are other factors that need to be taken into account.

 A recent media campaign would be a cue to action.

 The patient would need to work out the costs and benefits of the treatment as well.

Becker and Rosenstock (1984) 2 – – – Cost-benefit analysis.

Will the benefits outweigh the costs?

Barriers (or costs) might be financial, difficulty getting to a health clinic, not wanting to admit that they are getting old.

Benefits would be improved health, less risk from illness and less anxiety.

(Becker 1976).

 Perceptions of severity and susceptibility by the patient are related to compliance (Becker 1976).

(Becker 1976).

 Patients who believe they are likely to become ill and that this eventuality would have negative consequences are more likely to take some action.

 Simple beliefs regarding the likelihood that medication will improve the patient's condition are very potent determinants of compliance (Becker 1976).

 Actual severity of an illness is not related to compliance, but patient perception of severity is.

Abraham et al (1992)  Abraham et al (1992) studied 300 sexually active Scottish teenagers.  The seriousness of AIDS and the perceived vulnerability of contracting the illness were not the factors that influenced the teenagers.

 The awkwardness of use and the likely response from their partner, were seen as costs that outweighed the benefits.

Abraham et al (1992)  The teenagers therefore tended not to use condoms!  It would make sense to concentrate advertising campaigns on the barriers to condom use.

Problems  It is difficult to assess the health belief model as it is difficult to measure variables such as perceived susceptibility.

 Habits, such as cleaning your teeth are not easily explained by the model.

 The model has limited predictive value, but can be useful when trying to explain somebody's behaviour.

(Becker 1974).

 Any question of safety of treatment, side effects, or distress associated with treatment become very powerful suppressers and reduce the likelihood that patients will do as they were told (Becker 1974).

(Becker 1974).

 The Health Belief model is a comprehensive model.

 Revisions in the model have expanded its range to include intentions as well as beliefs (Becker 1974).

 Other models that are less comprehensive are the theory of reasoned action, protection motivation theory, Naive health theories and subjective expected utility theory.

Naive health theories.

 Patients often develop their own incorrect theories about their illnesses.  Such theories develop because a particular behaviour has become erroneously associated with an improvement in their condition.

Naive health theories.

 Such beliefs interfere with the understanding of the doctor's instructions.

 The instructions are interpreted so as to accord with their naive health theory (Bishop and Converse, 1986).

Naive health theories.

 The model has two strengths. – One is that it explains why a patient who intends to comply actually does not. – Secondly, the model is easily testable.

Rational non-adherence

 Sometimes the side effects of a treatment can be so devastating, that the patient decides, quite rationally, not to proceed with the treatment.  Bulpitt (1988) medication used for the treatment of hypertension reduced the symptoms of depression and headache.  However, the men taking the drug experienced increased sexual problems (difficulty with ejaculation and impotence).

Rational non-adherence

 Chapin (1980) suggested that 10% of admissions to a geriatric unit were the result of drug side effects.

 Most non-adherence in arthritis patients was owing to unintentional reasons (e.g. forgetting); the common intentional reasons were side effects and cost (Lorish et al, 1989).

Other useful concepts

1.

Behavioural explanations - habits, imitation (young smokers copying peers), reinforcement (short term treatment will provide this, but long term treatment would not). 2.

Defence mechanisms - e.g. smokers might use avoidance by avoiding information about the harmful effects of smoking. Also, they could use denial, pretending that smoking is harmless.

Other useful concepts

3 Conformity - e.g. men acting hard in front of their mates, and therefore not complying with their doctor's requests. 4 Self-efficacy (believe they can do something about the problem) and locus of control (feel that they have some control over the illness).