‘adherence i less likey, but tends to take place due to patients’ beliefs, attitudes and motivation. ‘Non-conforming: this involves ways in which melatonin Lak peso This could include missing doses, king medication at incorrect times or in incorrect doses. 8.2 Adherence to medical advice { Types of non-adherence and reasons why patients don't adhere Sahveronce has been defined by the World Healeh Organization (WHO) as, “the degree to which the person's behaviour corresponds with the agreed recommendations from a health care provider’, There are tyo.main types of nmadherence: failure to follow ‘The rate of non-adherence varies widely between studies and has been recorded at anywhere between 10% and 92% AHO carried out a review in 2003 and found that non-adherence to medication in developed countries ‘was approximately 50%. Approximately half of this non-adherence is considered to be intentional, and non- adherence is more likely with chronic (long-term) rather than acute (short-term) conditions. ‘rgatments and failure to attend appointments. There are ‘serious consequences to both types of non-adherence, both for the individual themselves and wider. adherence. how much a person's behaviour follows what their healthcare provider recommends and is agreed on World Health Organization (WHO): an ‘organisation within the United Nations, to direct international health advice and lead global health responses non-adherence: failure to follow treatments and. failure to attend appointments {Faure to flow treatmny can be broken down into ‘three different types Primary nonsidherence: this occurs when a doctor ‘writes a prescription, but the medication is never collesied: in other words, the patient does not hand in the prescription to get the medication they have been prescribed ‘Nop-persistence: this occurs when the patient starts to take the medication butstops, without being advised to do so by a medical professional. This is usually unintentional and often happens due toa miscommunication between the patient and the medical professional, or due to the patient's difficulty in following treatment due to issues such as cost, difficulty accessing medication, forgetting. to take the medication, etc. Intentional non- Failure to attend appointments is another problem. with non-attendance rates at primary care (general practitioners) in the UK being reported at between 2.9% tnd 11.7%, and in the USA between 5% and $5%. Problems caused by non-adherence mclude the following: + Waste of medication: if medication is received but not taken it is wasted, which has huge economic Consequences, as well potential issues relating to supply and demand. ‘+ Time lost due to missed appointments: research by the Doctor Patient Partnership and Institute of Healthcare Management in the UK found that 17 million GP appointments and 5.5 million practice nurse appointments were missed in 2000, at an estimated cost of £150 million. * Progression of illness: if medication is not taken the illness will most likely progress, leading to possible hospitalisation or stronger or more invasive treatments being required in the long-term. + Increased use of medical resources: related to the progression of illness, if untreated, a condition may ‘worsen to the point where the patient may require hospital visits, hospital admissions and admission to nursing homes. # Reduced functional abilities: if a disease or condition is left untreated it can affect the patients’ ability to function properly and may leave them unable to work, etc. ‘+ Lower quality of life: when left untreated, as well as the symptoms worsening, so will the quality of life of the patient, this will likely continue to dectine ‘nti or unless treatment is adhered to. Eo ES eee a)LE > CAMBRIDGE INTERNAT ‘+ Impact on medical research: researchers who are trying to establish the value of medications for target populations are less able to move forward ‘with their research if courses of treatment are not completed fully the negative implications are serious ting the individual tions for As we can see, ‘and wide-reaching, not just affect themselves but also having financial implica ‘medical services. Explanations of why people do not adhere ‘One explanation for why patients do not adhere (0 ‘medication i called rational non-adherence. This means that some people do not adhere because of a deliberate decision to adjust medication. There can be many reasons for this, including side effets, perception of the effectiveness ofthe medication and cost (2012) investigated rational non-adherence Example study ‘Laba'ét al (2012) carried out research to find out which factors contribute the most to rational non-adherence, and to investigate whether factors relating to specific medicines and patent background contribute 10 non-adherence. An online sampling system was used to collect a representative sample of 161 Australian participants. in terms of age and gender and included a Tange of education eve and income. ‘Ad onlinesuriey was used, which had thee sections: sectionane asked questions about current medication tse and attitudes towands medication and section thrge asked for background information about she participant. Section t0 was the Discrete Choice Experiment (DCE), where ten hypothet 3 were presented, and the participant was asked to choose from one of two alternatives. Participants were asked to smagine they ae currently taking to medications for differen long-term conditions, and were asked which of the two medications they would be happiest to continue taking. For each medication the participant would be ‘jven information regarding the following factors: * Symptom severity ‘© Symptom frequency while on the medication ‘©The chanee of early death from the iliness while on the medication ‘©The severity of the medication side effects TIONAL AS & A LEVEL PSYC! OLOGY: COURSEBOOK «sThechange of future unwanted medication side eta, How the medication is taken ‘Alcohol restrictions st to you of the medications -This was designed to find out which of the factors are thermos important in determining nor-adherence fo an ation, In total 32 choice sets were designed, and ‘hase were spit nto four versions of the surveys, along ice set to check for consistency and with a repeated choi Fationality behind the decision-making. Results showed that six out of the eight factors listed ‘Rove hada significant effect onthe decision to continue swith w medication. Symptom severity and alcohol ‘estrictions did not have a significant effect on adherence Participant background characteristics did not make a significant difference tothe effect of the factors, and either did it mater if participants were current taking medication or not. The monthly cost of the medication ‘was found to bea significant factor in non-adherence only Tor those who do not have private medical insurance (and therefore have to pay for medication themselves), but not for those with insurance (where the insurance company pays for the medication). Further analysis of the data Shows how participants were willing to trade between levels of factors, For example, participants would be significantly more willing to continue with a treatment if itonly needed to be taken once a day, compared to four times a day. However, they would prefer to continue with the task of taking the medication four times a day if it reduced ther risk of unwanted side effects inthe future by 20%. Analysis also showed that most participants. (58%) considered harms to be of greater importance than benefits when making decisions about adherence. Finally, the risk of current side effects was considered to.be more important than future side effects, however, the medication’ ability to reduce the risk of death ‘was seen to be more important than the reduction in symptom frequency. The Health Belief Model ‘The Health Belief Model is another explanation for ‘why people do not adhere. See the text on ‘Alternative explanations for delay’in Section 8.1 fora full description of the Health Belief Model. The factors described inthe Health Belief Model can be applied to non-adherence: * Perceived severity: somebody would be less likely to adhere to medication for a minor illness than for a more serious one. «The monthly co% 30)and feelin objective mi differe medication dispensers blood and urine samples Subjective measures ‘A subjective measure of interview. where the range of questions adhere! ‘medication. The Medics! Measure (MAM) i clinical int adherence. terms of that it allows + Peresived susce ikely to aahereto mediation hy dos they are at risk of illness. seat Se cena + Perceived benefits: Perceived ene sean es lf athe treatment will work, Sconce + Perceived barriers itahey perenive barren to bein ple chat inconvenience, cost, discomfort. a Cues to action 4 person is mor likely to medication if they have beer hake ave been exposed toa tee. ‘chs loved one dying rom simiar condition «Self-efficacy: som : sone is more likely 10 adhere edition f they have confidence that they en 8 TTanrough and keep up with the treatment plan Measuring non-adherence Patients’ non-adherence can be measured in a range of wnt ways including subjective measures such as Wetive measures such as pill counting and intersiew. obf rnd biological measures such as non-adherence isa clinical terviewed and asked a inding of their aherence is one example of a semi-structured aiviow designed to collect data about patients) eTys tems in the interview assess patients [9 vtledge of the prescribed treatment thi eported adherence any systems tse ‘Guch as medical dispensers OF fed barriers to adherence Pe MAM emphasise a supporting ip where advice and 1 patient is int to gather an understa \ce to their their kno has joner relationshi ed to incre rengths o! ase adherence a fhe interview are watients’ thoughts jer than the uantitative ws pout their treatment. Tat just count of track jeasures that. sure (MAI: 8 $200 ined to collect dat 8 Health psychology daaThe obvious wens of the meses that patent ay heathy te eng rrassment or uo fing ht hey imuruble Ipsec cea inert cs i aco Sippouve and colabortie ways tht fhe pate srencourged to eos con be a sures 0 Sa Example study 3) wanted oivestgte he a non nse eine as with chronic health conditions hos nho refused to partis WtShad? about treatment adherence woul show le iin adherence. doesent (aged 11-18 328) Whaltended «cline for type | diabetes and who Wed sae ua ome family member were approached nd | abot artim te std ftal the sample rane of ties. catgorscd nt thre OUP sore tat (who completed te whole to), 28 $2 parton agreed to take part nthe sy rn a ro atu i questionnaires) and 14 but ae tho completed the til aden nee ter and demographic information see Put ser eentnuc wth further questionnaire) eed the nial adherence ‘Shirt imeriew ven about diferent aspects ine Parents filled othe ich asked questions sity uber of Tt vas expected th ‘The adolescent compl interview, which was 2 asking a range of quest (of behaviour to manage t Gn overall adherence score emagraphie information sheet. spautthe adolescents age. gender th eomtaiaions and diese Sven Bs questions hoses arial talus nb Of a? aoe tro education Fushec aussionnays cand their parents to complet 294 sive pack ina prepaid envelope. 113s ts re yould take approximately he Pa a omplete an aed aU ala oi as ee ‘Molescents il tabs soo ne ROM len hd aout te eon tocol paras ha 8 i their rd nara 28 se wc terol she ela meee ony ind mest py aes wine MATHS) co oon of seo tm arson pans nonrees te a anaore between those . re ove ve nonseue TO gga om families 8 rou en that aes HT erence ifcantly higher naires had Sia gua sco fein fs sy aes as ee SS erp ees ex ad rng ie usin Sea and ng better organisation skills may | ‘be more likely t0: adhere at fort th questo ai ot ur th weadihcnant to dsc ses ao stent ithe Fes Objective measures Simple medical dyemsers, suc as seen in Figure 8.4 fan help measure adherence as they allow forthe correct {iblets to be placed in certain containers fr each day of the week. Therefore atthe end ofthe week w carer of tnedial professional can easly ee if there are any tablets ict inthe dispenser asa simple measure of non-adherence Similarly, pl couing is a straightforward way of measuring the amount of medication that has been taken: by asking patients to bring all medication at each medical review and counting how many pills emain at the end of a certain time period, you can easily calculate what percentage of prescribed medication a patient has taken. However, there are problems; fist, it relies ‘on the patient bringing all theit medication with them to each appointment. Second, you cannot know they 322) figure B.A: Areca DENSE on Help adherence se took the medication, just that itis ng jg ~ inte bottle, 90 ti easy for somebody to ‘9g i ihat they have not taken the medication ‘lem is that you are not able (0 track the thing a which the medication was taken, This is Pattern tleetronic measuring devices, such as the Figure 8.5) described by Tihany into play. They track when and how often amet im jeation is opened, allowing you, in theory Mrether medication is being taken atthe conn Sraay or at correct intervals, rather than js joe snany tablets are taken, The problem, however Tectonic measuring devices do not provide eviga that the medication is actually tog len dene Containers opened at certain times. A final poy Giuh electronic measuring devices is that they an strane so they eannot be used on a lege sa actually medical dispensers: products that alow Me oes wes acid Wesran ie for each day of the week my pill counting: by asking patients to b El mediation at each medical review and counting how many pills remain at the end of 2 certain time period you cn esl cae at percentage of prescribed cieaegianaly BowesFigure 8.5: The TreckCap 6 2 medical adh Example study ‘Chung and Naya (2000) wished to investigate the Cran ares of electronically measuring adherence effective ot fo medication in asbat nF and comps on pot ween ee 8 wee hak zafrukast, an oral mediation that eck worn AMte each three-week period, the patient reas ne for apical assesment ad (0 Te attended abet and have the bot replaced ih any umes epee weks worth of tablets Patients ane tof ad ocak one abet in the morning and ere mening. appronimael 12 hours apart. The 1 ed ha compliance was being measured te er cqady but were no old how this would fake place. The bottles of medication were fitted with @ ‘TrackCap medication ‘event monitoring system (MEMS) device, that recorded the time: ‘and date every time the ‘cap was removed and replaced. Days were classified as: sar acient interval arene: days wih (0 Insult than eight hours apart @ ~— Undercom| No compliance: days wih aocvent vemee: days with more ean two e018 2 Over-compl is important (0 as pat pliance: days with only one event pefore looking atthe results Fringuish between the ern ‘adherence and stance. The terms are On ‘used interchangeably Gar there isa slight disting’er ‘Compliance refers (0 a passive following OF ical orders, so inthis Ud) a Pipliance is measured PY ereentage of days wher comet amount of medication Taken. Adherence refers cormore of 2 collaboration etween doctor and Pac) 10 relates tothe patient sical 8 Health psychology svc ad llowins compa sca otha ing lifestyle to meet requirements. In is oth aa then a eppresnatt 2 co a approximately 12 hows aa 4 tostructed Rut fom the TackCap show that mann aan ‘and median compliance was 89%, Results va Show tna of pent had good ik a fet ds) on ay en eh lets were taken the meantime between tablet se 13 our 3 mice ih wih a Tints had one TrckCap event on a median of 19% of days. insufficient interval adherence on a median i SF 2a da pe ok bts oad were over compliant on 4 median of 2%of days. ‘eran of rw aca Taha compliance vssalue measured by a tablet count (how many tables wee ef ve at the ‘end of the trl period), Based on wriiplet count, median compliance was 927% 30 sightly of patients the TrackCap measure For 83 ge han Tack se a cei pk or, a SIE Fora minority of patents Howeve. eo vemored ore messin tt icappeay ay. and one aren ook upton Wek reser ete al ach opening T Tv supply ut erupt events before imi sits ugBEsing record gd able counting othe) reed tates Le tal hts non-compliance. Overall he 10. showed that compliance was conten high throughout the 12 weeks ‘and adherence, sof treatment tao lghly lower than compliance. was $Y ‘good altho aloo showed tat although complanss sr sre higher by use of tablet count than the east there was only sight diferene, 0 8 be rae tha the Trackap isan acrurate mes2iie of semplianee and adherence to medication. higher tl compliance: passive fllowing of medical orders, (2 ample the percentage OF d2ye where the Correct amount of medication 'S taken medication event monitoring S/o (MEMS) e and date root ora device that records ne evthe cop of a medicine container of every tim nd replaced: Trackap isthe was remove’ Brand used in this studyOGY; COURSEBOOK 10U' je PSYCH a yen esc Ee a ‘camer ANATIO iological measures gawd Ee Biologi ygherence, SU md ‘objective The maimed to measure non-adherence Biological measures of noma and urine samples tarred out when : carr tamples provide accurate readings 's vhict win slp ae em. extant ten’ are ter ruses of meni irae ete and oe 01 mony ai and eb me ‘sdatantage of hs mess fine dues thl ta onl ot be appropri jowever, the mail cre . to the others We wmpared 1 rarensie and takes time (0 0 fo use on a large scale rekert and Drotar used more than one MEBs | aerrence score ror the adherence intone | oth as numberof blood sugar checks, This | a ses the reliability ofthe findings as the reevarchers were able to test for consistency etween the two measures. By carrying out 2" interview and giving participants 2 Score, 25 well as recording the number of blood sugar ‘hecks, Riekert and Drotar were able to gather ‘Quantitative data, allowing for analysis and ‘Comparison between participants. However, & problem with the research is that itrelies on self report, so participants might not give accurate answers, ether because they want to deliberately hide the truth about their adherence, or because they may not remember accurately. Chung and Naya followed 57 patients in a clinical trial, so this was a relatively small sample. However, the trial was 12 weeks long, 50 this allowed reasonable length of time to measure the patients ‘compliance and adherence, increasing the valcity ofthe results. An important aspect ofthe trial was that the patients knew that compliance would | be measured as part of the research to comply | with ethical guidelines. However, the patients did not know that the TrackCap was used to take the ‘measurements. This was important because it ‘ensured the patients didn't change their behaviour 2 a result, but instead behaved how they naturally ‘would, so this increased the validity ofthe results. | Finally, as a way of measuring the accuracy of the TrackCap, compliance was also measured using pill counting, and the results were compared, methods us rer mothetic proach. LAFGE amount fd anotrlected in clinical als, and these da are ged to make generalisations about he ae ar population. One strenath ofa nomi wwecoach is that tis based on large amounts 2PEtatve deta, based on objective, sing further strength of a nomothetic © measures. A his that it allows for predictions to Pe make improverients, for example fining trays t help increase adherence, However ibe wey, weakness of a nomathetic approach, as Spposed to an idiographic approach, is thar eles not allow for people to be considered individuals. Furthermore, due to the lack of qualitative data and lack of focus on individu the nomothetic approach can't apply to everyone ‘hall and accurate detail, as the idiographic approach would. Improving adherence ‘As we have seen, non-adherence can have serious regative consequences, s0 itis really important to fing ‘ways to improve adherence. This could be through individual behavioural techniques, such as personalised prompts, contracts and customising treatment, or Through community interventions, such as the use of lotteries or generic prompts. Contracts can be implemented, whereby patients and ‘medical practitioners have a discussion to clarify the requirements of taking the medication. A contract is then drawn up and the patient signs it (or it can be verbal), to agree that they will adhere to medication (2007) carried out a review of previous studies and found that the use of contracts generally increased adherence to medication in patien's with a range of illnesses, but that there was little evidence of long-term improvements to adherence Prompts can be used to improve adherence, such as through reminder phone calls, text messages ot medication boxes. The use of prompts can help improe adherence in instances where the main cause of now adherence is forgetting to take medication or totake the prescription to a pharmacist. There has been mise«evidence forthe sucess of prompts but research by Strandbygaand etal (2010) ound that adherence to medication in asthma suferers increased signieanty if they received one text message a day to remind them CCustomising treatment can improve adberence a it ievoles adjusting the treatment regime to beter the Patient’ fesse orto make it easier or more convenicat for them to adhere. Evidence from Shi (2009) found that customs teatment by simpliying dosage frequency ammprove adherence to treatment and evidence rom Scodr (200) foun tat reducing twice diy to ‘once-daily dosing improved adherence. Another way of Customising tentment by changing the eaten to fede side effects. There is confiting evidence onthe ‘ff of minimising side effets on adherence but esearch Shows that thiscan improve adherence to treatment Example study ‘tal (2004) investigated improving adherence in children sufering from asthma. Asthma can be ‘8 dangerous condition, but luckily it ean be reated effectively, especialy in children, through the use of an inhaler, Research has shown that children often do not adhere to treatment and use their inhalers as they should, ‘and this is partly due to lack of adherence bythe children land partly due to lack of auherence by the parents because of the stress it causes to try to make children use their inhaler. Standard treatment for children with asthma favolves inhaling the medication from an inhaler with the tse of a spacer, to hold the medicine in place soit can be breathed in more easily (see Figure 86). Figure 8.6: A standard spacer used to help inhale asthma medicne “The study aimed to compare the adherence of children ‘with asthma using the Funhaler (see Figure 8.7), to those ‘sing the traditional spacer. The Funhaler is designed to set effectively as a spacer and to connect to an inhaler in the same way asa standard spacer but is made to be fun 8 Health psychology by adding a whistle and a toy element, When the child uses deep breathing the toy spins at an optimum level And the whistle wall sound; the idea being that using the Funhaler is fun, and correct use is encouraged. o aD Figure 8.7: The Funhalr i designed 10 improve adherence 10 asthma treatment (Chaney etal 2008) ‘A total of 32 children aged 15 10.6 years, with asthma who ‘used an inhaler and a standard spacer, were recruited 10 take part in the two-week study. Parents were contacted and asked to complete a questionnaire asking set of closed questions about attitudes and adherence tothe recommended treatment and frequency of medication. Participants were then invite to use the Funhaler for two weeks and were given the same questionnaire to complete after the two weeks were completed, Parents were contacted by phone on an ad hoe bass while using their standard treatment and the Funkaer, to be asked if their child had taken their treatment onthe previous day. Results from the random questioning of parents showed that 59% of children on their standard treatment had been medicated the previous day, compared to 81% winen using the Funhaler. Furthermore. when using their standard treatment children only achieved the recommended four or more breath cycles per treatment ‘0? ofthe time, but they achieved this 80% of the time using the Funhaler. When using the standard spacer, only 10% of parents reported being always successful with treatment, but this increased to 73% when using the Funhaler, There were far fewer problems such as screaming when faced with the spacer. or unwillingness to breathe through the device, wth the Funbaler than ‘withthe standard spacer. Finally, the attitudes of children and parents changed dramatically when responding to ‘the Funaler compared tothe standard spacer. Fear was atypical response tothe standard spacers, with only J0P% of children showing pleasure. However. there were no reports of fear in response to the Funhaler end in fact 70% displayed pleasure asa response. Only 10% of ‘parents reported their approach to the standard treatment, as being ‘completely happy’; however, 60% reported 2s >