Non-adherence

Question 1

Intro

Answer 1

• adherence - degree to which the patient’s behaviour matches an agreed treatment plan (Horne et al., 2005)
• worldwide problem of striking magnitude (WHO, 2003)
• challenge of non-adherence is still very much present (Graham et al., 2022)
• increased chance of dying is 2-3 fold (OCED, 2018)
• but adherence may not always be a good thing (Horne et al., 2005)

Question 2

Determinants of nonadherence

Answer 2

• important to identify barriers and those at high-risk of non-adherence and support development of interventions (Gast & Mathes, 2019)
• WHO (2003) suggest adherence affected by healthcare system, provider-patient relationship, disease, treatment, patient characteristics, socioeconomic factors
• social gradient to adherence (Gast & Mathes, 2019)
• daily pill burden and regimen complexity associated with poor adherence (Burnier, 2006)
• pre-existing beliefs about illness and treatment can affect adherence (Horne et al., 2005)

Question 3

Necessity-concerns framework

Answer 3

• proposed that key beliefs influence patients’ common-sense evaluations can be grouped into necessity beliefs and concerns (Horne, 2007)
• only focuses on patients conscious decisions not unconscious (Easthall & Barnett, 2017)
  Horne et al (2013) - meta-analytic review
• both associated with adherence/non-adherence
• useful conceptual model for understanding patients perspectives
• could enhance quality of prescribing by helping clinicians engage patients in treatment decisions
• necessity beliefs - perceptions of personal need for treatment
• concerns - about a range of potential adverse consequences
• but most studies used self-report so adherence may be over estimated
• development of more effective measures is needed
• suggests steps to facilitate adherence - no blame approach, tailoring support to individual needs, addressing perceptions as well as practicalities
• some interventions with this show encouraging results (Clifford et al., 2006; Elliot et al., 2008)

Question 4

COM-B (Mitchie et al., 2011)

Answer 4

• may provide theoretical basis for understanding medication adherence
• most factors can map onto COM-B
• more comprehensive than other theories/models - includes automatic processes system level factors, specificity of components and hypothesised relationship between them
• Jackson et al (2014) - mapped medication taking onto COM-B model into understanding adherence and advising interventions

Question 5

Intervention effectiveness

Answer 5

• evidence for effectiveness continues to be elusive (Donovan et al., 2022)
• cochrane review - most studies did not improve patient outcomes or adherence (Haynes et al., 2008)
• systematic review on hypertension - interventions had modest effect on BP but analyses lacked (Morissey et al., 2017)
• research includes short or non-existent follow-ups and no economic analysis
• successful interventions often involve a level of complexity too difficult and expensive to implement (Hayne et al., 2008)

Question 6

Intervention effectiveness studies

Answer 6

Stewart et al (2023)
- effective interventions scarce as many lack theoretical basis
- interventions better if tailored to specific perceptions of individual
- definition of adherence may be too strict - extent of adherence necessary varies between medicines and individuals
Gupta et al (2010)
- interventions most successful were complex, including combinations of patient education, simplifying dose regime, lifestyle advice etc - adherence needs to be considered in holistic way (Nieuwlaat et al., 2014) but effects inconsistent from study to study
- urine tests and a non-judgemental approach can change perceptions of benefits of meds in patients

Question 7

Technology interventions

Answer 7

• technological advances represent new and innovative modalities to improve adherence and overall health outcomes (Foremen et al., 2012)
• reviews arrived at mixed conclusions but many support their potential to enhance adherence (Fang et al., 2016)
• meta-analysis - text messaging can improve adherence (Thaaka et al., 2016)
  Donovan et al., 2022
• 2-way more effective than one way
• problem solving BCT - may reduce physical/psychological capability barriers
• feeback on health outcomes - increased reflective motivation
• prompt/cues - most common BCT but not seemed to be improving adherence
• limitation - many studies targeted behaviours in combination so influence of each is harder to separate, text messages varied so hard to compare

Question 8

Acceptance and commitment therapy intervention (Graham et al., 2022)

Answer 8

• research shows focus on motivation is needed not just information provision
• ACT shows promising results, improving adherence as outcome of improving self-management
• helps client make effective choices, given own personal goals and values
• can be used to supplement other therapy methods such as social cognition model
• non-adherence may be due to aversive qualities of treatments, ACT improves openness (opposite of experiential avoidance) so helps this
• adherence likely higher when person is clear on values and views treatment as value-based action - therapist helps define values, encourage Pp to view treatment consequences through lens of values

Question 9

Individual approach (Easthall & Barnett, 2017)

Answer 9

• motivational interviewing and health coaching show promise, especially in patients with psychological barriers
• highlights importance of tailoring to individual needs
• usual interventions offer practical solutions which helps unintentional but not intentional non-adherence
• but motivational interviewing would not help unintentional adherence
• education may help both but persuasive advice can evoke resistance in those not ready to change
• interventions should not be employed until reasons for non-adherence are established

Question 10

Stewart et al (2023)

Answer 10

• ethics of interventions - medicines have side effects so should ensure you’re helping patient make informed choices
• according to PaPA interventions should target both perceptual and practical barriers - address individuals’ motivation and ability
• existing interventions lack theoretical basis - challenging to make conclusions on why they have/haven’t been successful
• interventions often poorly described with little clarity on whats included (BCTs help this)
• future interventions should clearly describe content, theoretical basis and conduct process evaluations to ascertain how interventions may have worked
• interventions more effective when addressing both perceptual and practical barriers and intentional and unintentional considered as separate behaviours
• many interventions use one size fits all but perceptions and barriers vary

Question 11

Prevention (Chapman et al., 2024)

Answer 11

• starting new treatment seen as ‘critical period’ for risk of medication nonadherence
• much nonadherence occurs in this time
• not much research focused on how many patients don’t initiate treatment or why
• factors for nonadherence likely similar to non-initiation
• shared decision making may benefit adherence
• at initiation many meds have highest burden of adverse effects and smallest benefits
• prevention methods - reduce stigma at population level, improve initial prescription process (inform how meds work to address doubts, shared decision making), intervention mapping (Green et al., 2022) to screen for nonadherence risk factors
• group based interventions to increase social support may be helpful but place high burden on patients and healthcare practitioners