Adherence to medical advice

Question 1

what is adherence

Answer 1

Adherence to medical advice is when the health behavior of a patient corresponds to the medical advice given by their practitioner.

Question 2

what is non-adherence

Answer 2

Non adherence is when the patient does not follow medical advice, when the patient does not adhere to medical advice it has several repercussions to the health of the patient

Question 3

What are the types on non-adherence

Answer 3

1. Primary non-adherence - here patients get a prescription from the doctor but fail to collect the medication from the pharmacy.
2. Non-persistence - here the patient starts to take the medication but stop prematurely without being advised to do so by the doctor.
3. Non-conforming - here the medication is not taken as prescribed eg. Incorrect doses, missing doses, Incorrect timings. Etc.

Question 4

What are the repercussions to non-adherence

Answer 4

1. Lower quality of life - Here the suffering caused by the illness in the form of pain disabilities etc. May lower the quality of life for the sufferers.
2. Reduced function of abilities - due to non-adherence, the decese symptoms may worsen leading to functional impairment.
3. Increased use of medical facilities - if the condition worsens more hospital visits and admissions may be recommended by the practitioner.
4. Progression of illness - worsening of symptoms may lead to possible hospitalization, ore invasive treatments and sometimes death.

Question 5

Explanations for why patients dont adhere

Answer 5

1. Rational non-adherence (rational choice therapy)
2. HBM (health beliefs model)

Question 6

Describe rational non-adherence

Answer 6

Rational non-adherence (rational choice therapy)

• Patients fail to follow medical advice because they have a good reason for not doing so. According to sarafino (2006), some of the reasons for rational non-adherence include:
1. The patient believe that the treatment will not work. (Belief problems)
2. The side effects of the medication/treatment is extremely unpleasant.
3. You can’t afford the treatment.
4. Wanting to see if the illness will go away without medication.

Question 7

Describe the study by Bulpith and fletcher

Answer 7

• In this study the researchers wanted to know whether the elderly would contend with the unpleasant side-effects of the hypertensive drugs and follow the medical advice or whether they would drop out of the treatment regime prematurely, for fear of the unpleasant side-effects.
• Failure to use hypertensive drugs would mean the patients would contend with diseases such as heart disease, unstable Angina, or even death.
• Swallowing the medication would mean the elderly would have to contend with the unpleasant side-effects such as gout,dizziness, impotence, poor ejaculation, swelling and pain in the joints.
• Results showed that 8% of the men stopped taking the medication due to sexual problem, 15% of the men stopped due to tiredness, sexual problems and gout.
• Conclusion - when the cost of taking medication out way the benefits, then individuals will make a rational choice not to take the medication.

Question 8

Describe the study by laba et al

Answer 8

AIM:

• To investigate whether factors relating to specific medicines and patient backgrounds contribute to non-adherence.

SAMPLE:

• 1,668 invited to participate, however only 244 commenced the questionnaire and only 161 actually completed it.
• Hence sample is n=161.
• They were all from Australian adults who were all English speaking
• 45% were male 55% were female, they had a mean age of 57 years.

PROCEDURE:

• A survey was used to gather data, the survey had 3 sections.
• Section 1: asked questions about current medication use and attitude towards medication.
• Section 2: the discreet choice experiment - was conducted through a web enabled online survey. Task include :
1. Imagine you are currently taking 2 medications for different long term conditions. Which of those 2 medications would you be happiest to continue consuming, medication A or B? For each medication the patient would be provided with information regarding : symptom severity, symptoms frequency while on medication, chances of early death from the illness while on medication, alcohol restrictions, monthly cost etc. Which one would you prefer?

• Section 3 : data analysis.

RESULTS:

• Symptoms severity and alcohol restrictions did not have a significant effect in the decision to continue with medication A or B
• Monthly cost for medication was observed to be a significant factor to non-adherence only for those who did not have a private insurance.
• Participants would be more willing to continue the medication, treatment if it only needed to be taken once a day compared to 4 times a day. However they would prefer to continue with the 4 times a day regime if it reduced the risk of unwanted side-effects in the future by 20%
• The risk of current side-effects was considered to be more important than future risks side-effects.

CONCLUSION:

• Various factors relating to cost, convenience and risk of death, affect the patients adherence to the treatment regime.

Question 9

Describe the health belief model

Answer 9

• The HBM was developed to explain why people do not make certain preventive health choices eg. Exercising.
• The decision to engage in a health behavior depends on the outcomes of 2 Assessments :
1. Assessment of threat. Perceived severity (the more severe the symptoms of a disease, the more likely…), percived vulnerability (the more at risk a patient is to a disease, the more likely they will follow the medical advice), cues to action (demographic variables eg. Age, sex, inheritance.) Perceived benefits and barriers (cost, increase in quality of life,
2. Assessment of cost and benefits of engaging in a health behavior.

Question 10

Evaluate the health belief model and rational non-adherence

Answer 10

situational vs individual
situational explanation is the view that behaviour is caused by the environment the person is in. The rational non-adherence supports the situational side of the debate as it argues that situational factors are what stop people from adhering to medical advice. For example cost. In the study by Laba results found that monthly cost of the medication was a significant factor of non-adherence for the people that didn’t have insurance.

However the Health belief model supports the individual side. The individual explanation states that we behave because of our personality, as it argues that individuals make two assessments which determine their adherence. Assessment of threat e.g perceived severity and assessment of costs and benefits.

application to everyday life,

reductionism versus holism,
The health belief model is holistic. Holism is when all the components of a behaviour are studied. It is holistic as it identifies the several complex reasons why individuals do not adhere. For example it identifies the perceived susceptibility, perceived severity , the perceived benefits and barriers.

However the rational non-adherence is reductionism. Reductionism is when a complex behaviour/phenomenon is studied in isolation.
it is reductionist as it only identifies the “good”/rational reasons why patients don’t adhere to medical advice e.g cost of the treatment or the negative side effects of the treatment. It disregards the other plausible reasons for example perceived susceptibility here the individual considers how likely they are to develop the problem and base their actions on that.

Question 11

What are the measures on non-adherence

Answer 11

-Subjective measures
-Objective measures
-Biological measures

Question 12

Explain a self report as a subjective measure of non-adherence

Answer 12

-Here patients complete questionnaires explaining to what extent they have been adhering to their treatment plan
-A frequently used questionnaire is the 10 item MARS (Medication adherence rating scale) which has a forced choice format asking for yes or no answers and was originally designed to measure patients adherence to medication for schizo

Question 13

What are the subjective measures of non-adherence

Answer 13

-Clinical interview
-Self report

Question 14

Evaluate a self report as a measure

Question 15

Describe a clinical interview as a measure of non-adherence

Answer 15

This is a dialogue between patient and clinician to help the professional gain information which will help with diagnosis and treatment.

-A clinical interview can be structured or unstructured. The Medical adherence measure MAM , was designed as a semi structured clinical interview designed to elicit detailed and accurate responses from patients about whether they adhered to their treatment and included questions about diet, medication , clinical attendance

Question 16

Describe the example study by rickert and drotar subjective measures of adherence

Answer 16

Aim-
to investigate the effect of non participation in treatment adherence studies in adolescents diabetes

Hypothesis -
individuals who do not participate in the study will have low levels of adherence

Sample -
Adolescents aged 11-18 yrs , who attended a clinic for type 1 diabetes.
- They had to be living with at least 1 family member who was approached and asked to participate in the study.
-A total of 94 families were asked to take part; 80 originally consented but only 52 took part.

Procedure;
-The adolescents completed the initial adherence interview which was semi structured and asked a range of questions about different aspects of behaviour to manage their diabetes resulting in an overall adherence score.

The parents filled the Demographic Information sheet which asked about the adolescents age , gender, ethnicity, number of hospitalisations . It also asked questions about the parents level of education , marital status and how many kids they had.

patients were given more questionnaires to fill at home and mail back. The envelopes were pre-paid.

The parents questionnaire estimated to take 30 mins to complete and asked questions about their relationship with their child

-The adolescents questionnaire estimated to take 1 hour and asked questions about their relationship with their parent.

-The patients had a medical chart review which gathered information on their number of blood sugar tests per day and most recent level of metabolic control.

Results;
- Fathers education was higher for the participant group than for non-returners group.

-Those who failed to return their questionnaires completed significantly fewer blood sugar checks per day than those who did return their questionnaire.

Question 17

Evaluate the clinical interview

Answer 17

A strength ;
- it can provide detailed, rich qualitative data
about levels of adherence as well as reasons why they may not be adhering; for example,
in-depth questioning will provide detailed data that can help improve patient adherence by
providing researchers with a greater understanding of patients worries and concerns. This increases both the validity and the usefulness of the measure.

weakness;
However in comparison with questionnaires it is time-consuming and expensive method of gathering data and researchers may have
access to limited funding to conduct their research, which might result in smaller sample sizes.
It is also more time consuming for the patient who may have difficulties attending due to having to have time off work, for example, meaning that there may be a higher dropout rate than would occur in a questionnaire-based study, thus lowering the generalisability of the findings.

I

Idiographic versus nomothetic
The clinical interview supports the idiographic side as it uses in-depth interview techniques to discover why patients may not
be adhering to their treatment routine. By using an idiographic approach, practitioners can
better understand the specific issues that their patients might be facing rather than just
looking at generic issues that might not be appropriate for that patient. In this regard, an
idiographic rather than a nomothetic approach may be more beneficial.

Question 18

Evaluate the study by Rikert and drotar

Answer 18

One strength is that the study used a number of methods in order to ensure levels of
adherence were measured accurately. For example, the adolescents completed a clinical
interview and the parents completed a demographics questionnaire. Metabolic rate and use
of blood sugar equipment was also measured. This is a strength as the results of the study
are not reliant on one method alone. Each method has its own weaknesses so using more
than one minimises these weaknesses and increases the validity of the research.

Generalisability;
A weakness is that the sample was only taken from one clinic and was based upon one type
of illness - diabetes. Also, there were a number of potential participants who were asked
to take part but who did not consent to take part in the study.This makes the results not generalisable to the
wider population, or other illnesses.

ISSUES AND DEBATES

Application to everyday life
A strength of the study is that it has application to everyday life. For example, Riekert and
Drotar suggested that families who failed to complete the research tasks may have lacked
planning and organisational skills, which could also have affected how adherent they were
to the treatment plan. This may allow targeted interventions for those who do not take part
and ensure that a routine is established and understanding is high, which in turn will raise
adherence.

Question 19

What are the objective measures of non-adherence

Answer 19

-Medical dispensers
-pill counting
-

Question 20

Describe medical dispensers as objective measure

Answer 20

-These can help measure adherence as they allow for the correct tablets to be placed in certain containers for each day of the week.

-They allow you to organise medication by day and time. Automatic medication dispensers record the date and time the pill leaves the device and how often it has been used.

Question 21

Evaluate medical dispensers as a objective measure

Answer 21

-It provides a reliable way to measure adherence which is not affected by social desirability or errors of memory.

-It is an advantage to patients who are likely to stick to their treatment with reminders

-They may not get accurate results. Although the dispenser records the medication being removed it does not mean the perosn has taken the medication, It lacks validity.

-Usefulness of medical dispensers may vary with age, older patients show lower levels of adherence even with the use of dispensers, Some found the alarms irritating.

Question 22

Describe pill counting as a objective measure

Answer 22

This is a way of measuring the amount of medication that has been taken. Patients are asked to bring all medications at each medical interview and by counting how many pills reaming at the end of a certain time period. You can easily calculate what percentage of prescribed medication a patient has taken.

Question 23

Evaluate pill counting as a objective measure

Answer 23

-it does not measure how many pills the patient actually ingested. As the patients know they are going to be counted they can simply throw some away.This lowers the validity of the measure.
-It also relies on the patient bringing all their medication with them to each appointment. The patient may forget.
-Its also not possible to track the pattern in which the medication was taken

Question 24

Describe the example study by Chung and Naya
objective measures of adherence

Answer 24

Aim
-To investigate the effectiveness of electronically measuring adherence and compliance to medication in asthma patients

Sample;
-57 asthma patients
-Both male and female
-Aged 18-55

Methodology;
-In this 12 week trial patients were given 3 weeks worth of zafirlukast
-After each 3 week period, the patient attended a clinic for a physical assessment and to return any unused tablets and have the bottle replaced with a new set of tablets.
-They were instructed to take one tablet in the morning and one in the evening, approximately 12 hours apart.
-They were told compliance was being measured as part of a study but were not told how this would be done.
-The bottles were filled with a TrackCap medication event monitoring system (MEMS) device, which recorded the time and date each time the cap was removed and put back.
The days were classified as insufficient interval adherence , under compliance , no compliance over compliance.

Results;
-Median adherence was 71% and median compliance was 89%.

conclusion;
-Medication event monitoring systems such as Track Cap can be effective in measuring compliance.

Question 25

Evaluate the study by Chung and naya

Answer 25

Ethics -Although the participants were told that compliance was being measured there was some level of deception as they were not informed abt the trackcap Sample; -There was a small sample size of 57 patients all from London. This makes the results less generalisable to the general public. -Only 45/57 patients completed the study making the level of adherence different as they could be likely non-adherence if they counted even complete the study. Demand characteristics; -Participants may have been showing demand characteristics. The rate of adherence were high for this study however participants were aware that their adherence was being measured.

Question 26

What are the two biological measures of adherence

Answer 26

-Urine analysis -Blood sampling

Question 27

Explain urine analysis as a biological measure of adherence

Answer 27

Urine analysis: This is a fairly cheap way of collecting and testing for adherence. It is easy for the patient and totally non-invasive. In addition, urine is stable for up to 14 days at room temperature and with standard refrigeration. Also, urine sampling gives objective visual results unlike self- reports and for some patients where adherence is key to health, they find it reassuring that this has been evidenced through an objective test.

Question 28

Explain blood sampling as a biological measure of adherence

Answer 28

As well as traditional methods of blood testing, dried blood spot (DBS) testing can be carried out. DBS testing comes from collecting several drops of blood on filter paper. Drug levels in red blood cells can then be seen. Burnier (2020) showed that DBS testing can show levels of hypertension drugs reliably and that results were as high as using plasma. Plasma carries blood components such as nutrients, hormones and proteins through the body.

Question 29

Evaluate the biological measures of adherence

Answer 29

One strength of biological methods is that they provide an objective and visual cue for the patient and doctor about levels of adherence. Unlike subjective methods there is no social desirability bias from a blood test and therefore the results are reliable. The feedback from the test will allow a constructive conversation to be had between doctor and patient, especially if there are signs of non-adherence, meaning effects on health can be minimised. One weakness of biological methods is that drug/drug and drug/food interactions or differences in individual metabolism (rate at which drugs are broken down/used up by the body) of the drugs may interfere with how accurate the results are. Therefore, this method should not be used if patients are on more than one type of medication. Another issue with blood tests is that they are invasive and some patients find them unpleasant and stressful. Therefore, they are not a suitable measure for all patients. Therefore an idiographic approach to measuring non-adherence may be more appropriate so that people are not made to feel more stressed or uncomfortable.

Question 30

What are the ways of improving adherence

Answer 30

-Prompts -Customizing treatment -Behavioural contracts -Community based intervention

Question 31

Describe prompts as a way of improving adherence

Answer 31

-Sometimes patients forget to follow the prescribed medical advice/regime, when this happens they need reminders. this can be done through reminder phone calls, text ,messages or medical boxes. -Strandbygaard et al (2010) found that adherence to medication in asthma sufferers increased significantly if they received one text message a day to remind them

Question 32

Describe customising treatment way of improving adherence

Answer 32

This refers to adjusting treatment to meet the patients lifestyle.This increases convenience for the patient and they are likely to follow the regimen. Schroeder (2004) found that reducing twice daily to once daily dosage increases adherence. -Shi (2007) found that customising treatment by simplifying dosage can improve adherence.

Question 33

Describe behavioural contracts way of improving adherence

Answer 33

-Here the clinician makes an agreement that the patient has to sign regarding commitment to the certain target behaviours e.g i will not consume alcohol for the period of treatment. -These contracts could be verbal and written contracts between the patient and the clinician. -Neale (1991) found that participants who signed a behavioural contract agreeing to increase exercises and adapt a special diet to reduce cholesterol had significantly greater positive health changes than those who did not have a contract.

Question 34

Describe community based interventions as a way of improving adherence

Answer 34

e.g yokley and Glenwick

Question 35

Describe the study by chaney et al improving adherence in children

Answer 35

Aim; -To investigate the adherence of children with asthma using the funhalers to those using the traditional spacer. -To compare the effectiveness of the funhaler device and the standard spacer when parents are medicating their child. Sample; -33 children aged 1.5-6 years. with asthma who were already using the standard spacer to medicate themselves Procedure; Parents were contacted by telephone before any home visits were conducted. Informed consent was given and parents were interviewed using a questionnaire about the current asthma device. The questionnaire included questions about problems associated with the delivery of the medication and parental and child compliance with using the device. The Funhaler was not shown to anyone at this point. After interview completion, a Funhaler device was given to be used instead of the current device for two weeks (with adult supervision). The funhaler was an attachment device for use with metered dose inhalers. It has a fun toy module that can be attached with a spinning disk and a whistle. The device is designed to encourage the child to use their inhaler effectively. However, the toy itself does not affect the dose that the child receives. Parents were contacted once by phone at a random point of the study to see whether or not they had medicated their child the previous day. They were also visited at home once at the end of the two week trial and the parent completed second questionnaire regarding use of the Funhaler. This included yes/no questions as well as questions with predetermined responses from which the parents could choose the most appropriate answer about using the Funhaler and the original device and the children's response to it. For example: What was your child's attitude towards using the device? Results; There was a significant difference in the percentage of children who had been medicated the previous day , with significantly more children having been medicated using the Funhaler. There was a significant improvement in parents being able to successfully medicate their children using the Funhaler (current device = 10 per cent, Funhaler = 73 per cent). Conclusion; improved adherence suggested that the funhaler could be used to treat kids with asthma

Question 36

Evaluate the study by Chaney et al

Answer 36

Generalisiability; The study only had a small sample size of 33 Australian children making the findings not generalisable to the wider population. It also only showed differences in compliance between children who were already used to a conventional spacer meaning that the sample was limited not only to Australia but also to children who had already had experience of using a spacer in the first place. This lowers the generalisability of the findings. Another weakness is that the involvement of the parents in the research may have led to the high level of compliance shown. It may well be that it was not the use of the Funhaler that caused the results but just participating in the study alone. For example, the parents will have wanted to show that they were not neglecting their children's health so would have put in extra effort to ensure compliance therefore the results may have been the same with a normal spacer. This lowers the validity of the results. Useful application to everyday life; The study is useful as it offers a positive application of psychology and a device that could benefit young children with asthma and potentially reduce hospital admissions. This would benefit society as it would reduce the burden on the health services with fewer hospital admissions and in addition improve the lives of the young children with asthma, allowing them to lead a more normal life. Ecological validity; Another strength of the study is that the children used the Funhaler in their own home at the times when they would have ordinarily needed it and there was minimal contact with the researchers through the trial. This means that the results can be applied to real life situations as it was high in ecological validity.