Adherence to
Medical Advice
1.
REASONS WHY PATIENTS DO NOT ADHERE
2.
MEASURING ADHERENCE AND NON ADHERENCE
3.
IMPROVING ADHERENCE
Reasons for non-adherence: cognitive
rational non-adherence

Adherence is all about being conscientious in following medical advice.

This section looks specifically at following recommendations for taking
medication

Starter - Work sheet
Why is adherence a problem?

Studies have suggested that
about half of the patients with
chronic illnesses such as diabetes
and hypertension (high blood
pressure) are non-compliant with
their regime. There is clearly a
large financial cost for this in
wasted drugs but also potentially
in poor health outcomes.
A study by Sackett (1976)

50% of patients in America did not take
prescribed medications according to
the instructions and scheduled
appointments for treatment were
missed 20-50% of the time.
Taylor (1990) suggested that 93% of patients fail to adhere to some aspect of
their treatment.
Sarafino(1994) argued that people adhere reasonably closely about 78% of the
time for short-term treatments but only 54% for chronic illness.
A study by Becker (1972) looked at whether a prescribed anti-biotic was being
taken halfway through a 10 day treatment programme in young children. Over
half the mothers had stopped giving the medicine.
McKenny (1973) looked at hypertension
He studied 50 patients for 7
months. After detection of high
blood pressure only 50%-70%
sought treatment
 He found that only 65% of pills
were taken.
 Only 20% of the patients took as
many as 90% of the pills.
 33% of those who sought
treatment dropped out.
 The question is why?

Why patients do not adhere!

Rational Choice Theory: people may not adhere for good
reason:
1.
They have reason to believe the treatment is not working
2.
The side effects are unpleasant or effect the quality of their lives
YouTube - Ambien Side Effects -- Research Findings
3.
There are practical barriers to the treatment such as cost or
social difficulties (HBM)
4.
They may want to check the illness is still there when they stop.
Rational non-adherence

The patient may not believe
what the doctor has suggested
is in their best interest. Bulpit
(1988) looked at treatments for
hypertension and found that the
side effects could include
impotence and problems with
ejaculation. Clearly for some
men this would be seen as
unacceptable!
Bulpitt: Rational Non Adherence

Aims: to review research on adherence in hypertensive patients.

Method: Review article of range of research which identified problems with
taking drugs for high blood pressure.


Review – Research was analysed to ID physical and physiological effects of new drug
treatments on a person’s life (Including, hobbies, work, physical well being)
Findings:
+ Drug did reduce headaches and depression compared to old drug
- Side effects: reduced circulation of blood (leading to erectile dysfunction,
sleepiness, dizziness and problems with cognitive functioning. Affecting work and
hobbies.
Bulpitt: one study by Curb found that 8% of men stopped taking
their medication due to sexual problems.
 Research by the Medical Research Council found that 15% of
patients had stopped taking the drug due to other side effects.


Conclusions of Bulpitt’s review were that the costs of taking
some medication appear to outweigh the benefits for many
patients, especially with problems such as high blood pressure
which have no symptoms. Therefore some types of treatment
(asymptomatic ones) may be more difficult to treat as people
cannot feel the benefits of the adherence.

Application?
Evaluation

Review – wealth of data (several countries) – holistic picture of effects of
taking medication for hypertension

However, different methods – difficult to test reliability

Survey data – memory and social desirability

Debates:

Psychology as a science – rigorous picture: Incorporating vast amounts of
qualitative data

Usefulness – Medical practitioners should be aware of the difficulties male
patients will have in particular when taking these medications
Cognitive / Behavioural Theories of
Adherence: Locus of Control – Rotter

The more a person feels in control the more likely they are to comply
with their treatment programme.

If we have an internal locus of control we are likely to have a higher
self efficacy – more belief in what we do makes a difference.
Other theories to explain
non/adherence:

Psychoanalytic explanations include avoidance and denial of the
problem
H/W

How can fear arousal be used as a method of health promotion? (10)
Measures of Non-adherence:
Physiological
Different methods of measuring adherence.
Complete second part of table
1.
Self-report – simply asking people - probably with questionnaires
2.
Therapeutic outcome – have they got better?
3.
Pill & bottle counts – raid the cupboard and see what is left!
4.
Mechanical methods – how much medicine has been dispensed from the bottle?
5.
Record number of repeat prescriptions
6.
Biochemical tests - blood and urine
Which of these methods are subjective/objective?
How effective are each of these methods?
1.
YouTube - Medication Adherence
Don’t ask Drs about adherence

One of the least affective
ways (Ley 1997) of
measuring adherence is to
ask doctors as they appear
to vastly over estimate the
extent to which their
patients do adhere.
Chung and Naya 2000 – Mechanical method

Was the first study to electronically
assess compliance with an oral asthma
medication.

Aimed to see if patients did take their
medication regularly and at the
correct time of day.

Taking regular asthma medication
reduces attacks and prevents deaths.

This study used an electronic Track
Cap, an electronic device on the
bottle top that recorded the date and
time of the use of the medication.

57 Patients were told that adherence rates were being measured but not told about the
Track Cap device and what it did. The treatment was taken twice a day 8 hours apart.

The study was carried out over a 12 week period.

Compliance was measured by the number of times the track cap was opened, the number
of days and number of pills left

Over the period the track cap monitoring showed compliance was quite high at 71%.
However the count of returned pills put the compliance rate even higher at 92%.

Mechanical method effective method to measure adherence.

However – could patients have been influence by being told what was being measured?
Physiological methods

Lustman (2000)

Physical measures such as blood sugar levels can indicate adherence to a
medical regime

Glycohaemoglobin (haemoglobin with glucose attached , GHb) will show
levels of glucose in blood

Insulin – should keep levels normal

Therefore adherence can be measured by measuring Ghb
Lustman et al. (2000)
Using
physiological measure to assess adherence to medication and the treatment of
depression in diabetics.
Aim:
to assess the effectiveness of fluoxetine as treatment for depression in patients
with diabetes by measuring gylcemic control
Method:
lab experiment using a double blind technique and placebo control
Participants:
Had
60 patients who volunteered to take part (self-selected sample)
either type 1 or type 2 diabetes and had been diagnosed with depression.
Procedure: All patients screened for depression using the Becks
Depression Inventory
Randomly
assigned to 2 groups
Grp
1: given fluoxetine
Grp
2: identical looking pill as placebo
Assessed
Daily
for depression – psychometric tests
does of medication for 8 wks
Patients
and docs did not know to which group they had been
assigned – avoidance of demand characteristics
Adherence
to medical regime measured by GHb levels
Findings:
Reduction
in depression symptoms was significantly greater in
patients treated with fluoxetine compared with those receiving the
placebo.
Researchers
were able to measure levels of GHb this indicated
improved adherence to their regime.
Conclusions:
Measuring
blood sugar levels in patients with diabetes indicates
their level of adherence to medical regimes.
Greater
adherence shown by patients who were less depressed,
suggesting that reduced depression may improve adherence in
diabetic patients.
Evaluation

Discuss

Psychometric and blood tests- Findings reliable

Small sample

Results taken after a short while (depressants take some time to work)

Rigorous design – restricts bias

Reductionist? (using alteration in brain chemistry through drugs rather than
looking a whole lifestyle)

Useful – Evidence that adherence to a physical treatment could be affected
by mental focus
Improving Adherence - Using
behavioural methods

Complete the third part of the table

Many ways to improve adherence

Reduce costs (so that costs don’t outweigh benefits)

Study demographic variables of HBM (eg gender)

Look at perceptions of susceptibility and severity

LOC can influence adherence

Emphasising information and key details (Cowpe) and not using jargon (Ley, 1973)

Lewin (1992) info and instructions

Behavioural strategies – using reinforcement for correct adherence
Watt et al. (2003)
Study used behaviourism and reinforcement for correct adherence thus a
‘funhaler’ with a whistle and spinner were used to reward children for using
inhaler correctly.
Funhaler:
https://www.youtube.com/watch?v=6xhh8PowaKs
Look up study in textbooks

Aim: Improving adherence without compromising delivery. To see if using
funhaler would improve children’s adherence to taking medication for asthma

Method: Field and quasi

2 conditions

Self report to measure adherence rates

Details: 32 Australian children (10 males, 22 females) 1.5-6 years

Diagnosed with asthma, prescribed drugs delivered by inhaler.

Parents gave informed consent

Each child given ‘breath-a-tech’ to use for one week


Second week children used the ‘funhaler’


Questionnaire for parents to complete
Parent given matched questionnaire after the second week
Calculated the volume of air in the funhaler and thus the amount of
Medication absorbed by the child

Results:

38% more parents reported higher adherence in the children when using the funhaler

60% more children took the recommended four or more cycles per aerosol delivery when
using the funhaler

Conclusions: Previous research: non adherence in children with asthma due to boredom,
forgetfulness and apathy. Funhaler set out to remedy this by reinforcing correct usage with
a toy.

This did improve the adherence to the medication. So by making the medical regime fun,
the adherence, certainly in children, can be improved.

Evaluation

Self report – social desirability

Validity – IV well defined and manipulated

Useful – implementing reinforcement can increase adherence

Generalisability – asthmatic children only (sal sample)

Reductionism – wider causes of adoption of health behaviours?

Construct validity – support for behavioural operant conditioning

Ethnocentric?

Snapshot?
Make sure your patient is not
depressed.

Studies have shown that
often people who are ill
are depressed or anxious
and that treating the
patient in a more holistic
way (treating their
psychological or
emotional health as well
as their physical health)
can have a great effect.
Use the Behaviourist Approach to
improve adherence
1.
2.
3.
4.
5.
Feedback and self monitoring the patient gets regular reports on the
state of their health so reinforcing their adherence
Contingency contracts the patient negotiates a contract with the health
worker concerning goals and rewards for achieving their goals
Modelling the patients sees someone else who is successful in a support
group or as a mentor etc.
Direct reinforcements or incentives like being given money to continue
on a programme or come off drugs
Punishment In New York laws were changed so that people had to take
the treatment (tuberculosis) and come to the clinic and be seen to take
it or face compulsory admission to hospital.
Problems with Adherence and
Measuring adherence

Operationalising the variables of adherence is very
difficult and different studies may do this in different
ways making it difficult to compare studies.

For example is someone who just misses one dose
non compliant ? If they just take it at the wrong
time of day is that non compliance? If they take
the wrong amount how much becomes non
compliant – it will surely depend on the disease and
on the medication.
Ethics

For example: the best way would be to use scientific methods like
blood tests but this is unethical. It is also unethical to observe people
in their homes.
Social desirability bias and
demand characteristics

For example: 286 patients were asked about compliance with a
questionnaire whilst at the same time electronically monitoring their
medication.

21% admitted to missing a dose in the questionnaire but the
electronic monitoring showed the true figure to be nearer 42%
Advantages of measuring and improving
adherence

Usefulness is a really important evaluating
point for this section as obviously there are
huge costs involved not only actual cost in
terms of wasted medication but huge
costs in terms of poor health and
increased hospital admissions.

For example it has been estimated that up
to 70% of hospital admissions could be
prevented if patients had been more
adherent to previous health requests.
Scientific nature of some tests

Blood and urine tests are
highly reliable as they are
scientific

Mechanical tracking
devices like the track cap
are also more reliable then
the self report method.
Blood Tests

Blood tests maybe
highly unethical and
also expensive to
administer. You also
would not be able to
tell how often or how
regularly the medicine
had been taken as
they may just have
taken the medication
before the blood tests!
Cost benefits

HBM - Society has to weight up the costs and benefits of actions against
non adherence.

Some such as expensive pill counting measures, producing funhalers or
blood tests may simply be too costly but others such as making sure written
information is given to each patient would actually be cost effective in the
long run.
Reductionism
It is important not to be reductionist when
considering adherence
 For example it is reductionist to assume that non
adherence is as simple as making a rational choice.
 The reason for adherence may be a complex
interaction between past positive or negatives
experiences (behaviourism) and early trauma
(psychodynamic) combined with biological side
effects which may be very individual to one
particular person.

Individual v situational



The situational hypothesis would predict that
adherence will differ in the same individual
depending on the situation they are in:
For example….
when at home or on holiday it may be easy to take
medication by leaving it in an obvious place that is
noticed but this maybe more difficult if the person is
at work.
Exam questions – 10 markers
January
2010
Describe
one way to measure non-adherence to
medical advice. (10) HWK
January
2012
Explain
why people may not adhere to medical
regimes. (10) (Rational Choice Theory – Completed)
June
How
2013
could adherence to medical regimes be
improved? (10) TIMED CWK

Group task

In pairs, answer the following questions

Please title your work ‘group classwork’: adherence to medical regimes

1. Discuss the difficulties of researching adherence to medical regimes. (15)

DON’T FORGET TO ALWAYS BACK UP YOUR POINTS WITH EVIDENCE AND TRY
TO ENSURE BALANCE IN YOUR ANSWER

SOME POINTS TO CONSIDER:
-
Research could impact professions
-
Defensiveness from individuals
-
Sensitive nature of the topic
-
Ethics
-
Demand characteristics
-
Social desirability
-
The methods themselves
Exam questions – 15 markers

January 2010

Assess the reliability of research into non-adherence to
medical advice. (15)

January 2012

Discuss the difficulties of researching adherence to
medical regimes. (15) – GROUP TASK

June 2013

Discuss the usefulness of research into adherence to
medical regimes. (15) - HWK