Patient attitudes to meds & med adherence

Question 1

Attitude definition

Answer 1

• A settled way of thinking or feeling about something
• A feeling or opinion about something or someone, or
  a way of behaving that is caused by this
• Attitudes affect our behaviour

Question 2

behaviour definition

Answer 2

• The way in which a person behaves in response to a
  particular situation or stimulus
• Behaviour is often informed by attitude

Question 3

Why are behaviour & attitude important to pharmacists?

Answer 3

• Understanding behaviour in health
  consultation assists understanding medication
  taking behaviour
• Pharmacists need to understand patient
  behaviour in consultation to help patients
  optimise medicine usage and deliver person-
  centred care
• Optimisation important for achieving clinical
  and cost related outcomes

Question 4

Medication taking behaviour

Answer 4

• Compliance
• Adherence
• Concordance

Question 5

What is compliance?

Answer 5

• The extent to which the patient’s behaviour
  matches the prescriber’s recommendations.’ However, its use is declining as it implies lack of patient involvement.

Question 6

What is concordance?

Answer 6

• Focused on the consultation process, in which
  doctor and patient agree therapeutic decisions that
  incorporate their respective views, to a wider concept which stretches from prescribing communication to patient support in medicine taking

Question 7

What is Adherence?

Answer 7

• Most used term
• The extent to which the patient’s behaviour matches agreed recommendations from the prescriber.
• 33- 50% of patients on long-term treatment do not
  take medicines ‘correctly’ as prescribed.
• Patients s/t make decisions about meds based on their understanding of their condition , the treatments & their view of their need for the med & their concerns.
• Ask patient what they know & believe about their med & its need before prescribing & reviewing meds.
• Address their concerns
• They need to be aware of what will happen if they don’t take the med
• non-pharmacological alternatives
  – reducing or stopping long-term medicines
  – fitting medicines into their routine
  – choosing between medicines.

Question 8

What can med wastage result in?

Answer 8

• Lack of patient adherence can result in long-term costs as their in willingness to take the med could result in them having worse effects or issues which cause them to go to the hopsital for longer = more meds= costs more.
• Meds wast = estmated £300 MIL

Question 9

Promoting adherence through person centred care

Answer 9

• Person-centred is about focusing care on the needs
  of individual.
• Ensuring that people’s preferences,
  needs and values guide clinical decisions, and
  providing care/treatment that is respectful of and
  responsive to them.

Question 10

What are the 2 types of Non- adherence?

Answer 10

• Intentional
• non-intentional
• Any types of non- adherence should not be seen as the patients problem.
• It represents a fundamental limitation in the delivery of healthcare, often because of a failure to fully agree the prescription in the first place or to
  identify and provide the support that patients need later on.

Question 11

What is intentional non-adherence?

Answer 11

• Related to attitudes, beliefs
  and concerns or problems about the
  medicines

Question 12

What is Non-intentional Non- adherence ?

Answer 12

• practical problems..
• i.e Jobs or patients work schedule/ pattern can make it diff to adhere to a med schedule

Question 13

Non- adherence could be due to patient fears , what are the fears patients may have?

Answer 13

• Addiction (to the meds)
• Psychological dependence
• Concerns about tolerance
• ‘Drug holidays’ (patient stops taking the drug for a set period of time can help to reduce side effects)
• Fear of masking symptoms of the disease
• Manufactured medicines are unnatural

Question 14

What other factors influence the decisions of taking meds?

Answer 14

• Cost – ability to pay
• Repeat prescribing arrangements
• Interruptions to daily routine
• Being away from home
• Forgetfulness
• Stress
• Lack of access to services/ appointments

Question 15

How to measure adherence & non-adherence?

Answer 15

• assessing non-adherence by asking the patient if they have missed any doses of medicine recently
  Make it easier for them to report non˗adherence by:
• asking the question in a way that does not apportion blame
• explaining why you are asking the question
• mentioning a specific time period such as ‘in the past week’
• asking about medicine-taking behaviours such as reducing the dose, stopping and
• starting medicines

Use records of prescription re˗ordering, pharmacy
patient medication records and return of unused medicines to identify potential non˗adherence and patients needing additional
support.
- though this does not always mean that the patient is actually taking their meds

Question 16

Measuring adherence/non-adherence

Answer 16

1- Direct measures e.g. blood tests , urine or drug tests
-Adv= Most accurate Can provide physical evidence
-dis= Generate a Yes/No result only, intrusive, Varied drug metabolism
2- Pill count
- Adv= Low cost ,Simple
- dis= Not for ‘as required’
medications, cannot estimate medication-taking pattern
3- Measures involving clinician assessments and self-report= most comon i.e how often do you collect your prescriptions?
- Adv= Low cost, easy to administer, can identify belief and barriers to adherence
- dis= Least reliable, affected by communication skills of
interviewers and questions in the questionnaire
Patient’s desirability can bias
- self reported = have to assume that what teh patient is syaing is true which is not always the case.

Question 17

What is the hill- Bone scale?

Answer 17

• Measure adherence to high blood pressure meds
• Score of 1- 4
• 1= all the time
• 4= none of the time
• score 9 = perfect adhernce
• score 36 = total adherence

Question 18

How can you promote adherence?

Answer 18

• a frank and open approach which recognises that non˗adherence is very common and takes a no˗blame
  approach, encouraging patients to discuss
• non˗adherence and any doubts or concerns they have about treatment
• a patient˗centred approach that encourages informed adherence
• identification of specific perceptual and practical barriers to
  adherence for each individual
• both at the time of prescribing and during regular review, because perceptions, practical
• problems and adherence may change over time.

Question 19

What are the Key principles for promoting
adherence?

Answer 19

• Adapt consultation style
• Make patients involved
• Patient has right not to take their medicine
• Be aware that patients’ concerns about medicines- e.g
  becoming dependent on medicines, and concerns about
  adverse effects. Address these concerns.
• Provide information- do not assume patient information
  leaflet will provide the information
• Tailor any intervention to increase adherence to the specific
  difficulties with adherence the patient is experiencing

Question 20

Principles to follow for good Communication about prescribed treatments

Answer 20

• Shared decision making
• ## Need consideration of both benefits and issues

Question 21

The clinician brings:

Answer 21

• knowledge & skill to interpret cause
• & potential treatment

Question 22

The patient brings

Answer 22

• Their illness
• Their interpretation
• Their problems
• Their values

Question 23

What is Kleinman’s Model?

Answer 23

• Eliciting the patient’s (explanatory) model gives the
  healthcare professionals (HCPs), the knowledge of
  the beliefs the patients holds about their illness, the
  personal and social meaning they attach to their
  disorder, their expectations about what will happen
  to them and what the HCP will do, and their own
  therapeutic goals
• Works w/ teh patient & undertsnds their beleifs & values

Question 24

Kleinman’s Model

Answer 24

• What do you think has caused your problem?
• Why do you think it started when it did?
• What do you think your sickness does to you?
• How does it work?
• How severe is your sickness?
• Will it have a short or long course?
• What kind of treatment do you think you should receive?
• What are the most important results you hope to receive from this treatment?
  What are the chief problems your sickness has caused for you?
• What do you fear most about your sickness?

Question 25

How can we promote adherence?

Answer 25

• review medications, effectiveness, side effects
• suggesting that patients record their medicine˗taking
• encouraging patients to monitor their condition
• simplifying the dosing regimen
• using alternative packaging for the medicine
• using a multi˗compartment medicines system
• communications across healthcare professionals
• Apps/reminders
• Communicate Risks f the med or tretment & make sur wetehy understand

Question 26

What is COM-B model of behaviour?

Answer 26

Capabilty =
- Are they physically & mentally capable? can they take med through the route?
- Influenced by physical factors such as dexterity or eyesight, and psychological factors such as knowledge and memory.
Opportunity=
- Their daily lifestyle may not sit well w/ the prescribed routine.
- nfluenced by factors such as environmental constraints, such as difficulties getting to pharmacies; social factors such as stigma for HIV patients’ medication taking behaviours.
Motivation=
- Self-confidence & beliefs
- Do they believe it really works or that it is important

Question 26

Another way to promote adherence

Answer 26

• DOT = Directly Observed Therapy
• specific stratergy to imprve adherence to anti-tuberculosis meds by requiring helath workers , volunteers or family memebers to observe & record patiet taking each dose.
• Endorsed by Word Health Organistaion

Question 27

What other theoretical models are ther for understanding & promoting adherence?

Answer 27

• COM-B
• Theoretical domains framework (TDF)

Question 28

Whta is the TDF ( Theoretical Domain Framework)?

Answer 28

• TDF is a theoretical framework of determinants of behaviour
• Combines 33 theories into 14 domains
  1. Knowledge
  2. Skills
  3. Social/Professional Role and Identity
  4. Beliefs about Capabilities
  5. Optimism
  6. Beliefs about Consequences
  7. Reinforcement
  8. Intentions & Goals
  9. Memory
  10. Attention and Decision Processes
  11. Environmental Context and Resources
  12. Social Influences
  13. Emotions
  14. Behavioural Regulation