Session Nine (Non-Adherence)

Question 1

What are the differences between Fulfilment, Compliance and Adherence?

Answer 1

Medication Fulfilment = the process by which a person actually acquires their medication, e.g. picking up their prescription from the pharmacy

Compliance to Treatment implies a person is following a doctor’s orders without any involvement

Adherence to Treatment implies they are sticking to an agreed upon line of treatment, emphasises the role of the patient during the agreement phase.

Question 2

What does 2009 NICE guidelines say about adherence?

Answer 2

• Should no longer be viewed as a problem with the patient
• Problem lies with the failure to agree to a prescription in the first place or a failure to identify and provide the support a patient needs to carry out the treatment.
• Represents a fundamental limitation in the delivery of healthcare.

Question 3

What is included under the term Adherence?

Answer 3

• Taking medications
• Attending follow up appointments
• Lifestyle changes
• Monitoring tests

Question 4

What are the 3 types of non-adherence?

Answer 4

• Primary NA/ Fulfilment: Not filling out a prescription
• Secondary NA: Overusing it, Missing doses, Changing dose amount or frequency, Changing the timing of doses
• Non-Persistence: Not continuing the treatment for the prescribed duration

Question 5

What proportion of therapies are not adhered to?

Answer 5

30-50% of all medicines prescribed are thought to not be taken as directed. These numbers are probably worse for lifestyle changes and chronic, long term conditions.

Question 6

Why is increasing adherence so important?

Answer 6

Better adherence leads to:

• Slowed disease progression
• Reduced morbidity and mortality (200k/year due to NA)
• Reduced disability
• Increased QoL
• Reduced healthcare costs (potentially wasting 4 billion pounds a year)
• Reduced unnecessary treatment escalation
• Reduced societal and workforce costs

Thought that increasing adherence would have a greater benefit than any new implementation

Question 7

What are some recognised barriers to treatment adherence?

Answer 7

• Side effects
• Method of delivery
• Ability to collect drugs
• Lack of immediate benefit
• Symptoms disappearing before treatment complete…

Question 8

What are the important myths around who doesn’t adhere to treatment?

Answer 8

• NA has nothing to do with the disease, it’s seen in all conditions no matter how serious or long term
• NA has nothing to do with the SE factors of the patient, significant variation seen in all demographics, as well as in individuals relating to different medications/ diseases/ times in their lives.
• NA can’t be ‘easily’ fixed by providing adequate information, or reminders, or threats or fear.

Question 9

What is the evidence regarding the link between complexity of regimen and Adherence?

Answer 9

Mixed. Claxton et al 2001:

• Showed that simplifying a regimen can be helpful for some patients
• However, did not totally resolve NA issues
• NA appears to arise more from difficulty of fitting medication into daily life than complexity per se

Question 10

What is intentional and unintentional non-adherence?

Answer 10

INA = Deliberately choosing not to take a medication.
UINA = Forgetting/ not being able to take a medication

Important to remember that for many patients the reason they don’t take their meds falls somewhere between the two e.g. more likely to forget (UI) a medication you don’t agree with (I)

Question 11

What is important to remember when dealing with Intentional NA?

Answer 11

Decision may seem illogical to us, but the patient will certainly have made a logical decision not to take their medications. Getting to the route of this decision making process might be key to getting over this NA issue.

Question 12

How can we assess a patient’s adherence to medication?

Answer 12

• Self report methods
• Direct observation of treatment
• Can look at pharmacy dispensing records (although this only tells us about fulfilment not adherence)
• Pill counts
• Can do blood tests
• Medication Event Monitoring Systems (MEMS)
• Intelligent Drug Administration Systems
• Ingestible sensors
• Smart blisters that send a signal when popped
• By clinical outcome

Question 13

McHorney (2008) Reviewed all factors believed to be associated with NA, with what factors did he find WEAK evidence for an association?

Answer 13

DEMOGRAPHIC FACTORS:

• Gender
• Income
• Age
• Race
• Personality

Question 14

McHorney (2008) Reviewed all factors believed to be associated with NA, with what factors did he find MODERATE evidence for an association?

Answer 14

COGNITIVE or PSYCH FACTORS:

• Cognitive ability
• Depression
• Social support
• Coping skills
• Number of medicines
• Disease seriousness beliefs
• Health literacy
• Locus of control
• Self efficacy
• Trust in HCP
• Symptom experience

Question 15

McHorney (2008) Reviewed all factors believed to be associated with NA, with what factors did he find STRONG evidence for an association?

Answer 15

Largely ILLNESS/TREATMENT FACTORS:

• Concerns about treatment e.g. fear of SEs
• Beliefs about illness (cause, timeline)
• Cost of therapy
• Necessity (including perceived)
• Perceived drug efficacy

Actually provides pretty good evidence or every model of NA tbh.

Question 16

What is a common issue with self reported measures of adherence?

Answer 16

• Patients quite often lie about how much they adhere to therapy
• Self-representation bias
• Can work around this by using a scale such as the Medication Adherence Report Scale (MARS) which attempts to normalise NA in order to elicit a more honest response
• Rather than asking do you adhere its more do you forget and if so how often

Question 17

What is the Perceptions And Practicalities Approach to NA?

Answer 17

Framework that explains NA in terms of practical factors and perceptual factors:

• UI NA is driven by a patient’s capacity and recourses, their PRACTICAL factors
• I NA is driven by a patient’s motivations, beliefs and preferences, their PERCEPTUAL factors

Question 18

What are some examples of Practical factors that might get in the way of adherance?

Answer 18

• Manual dexterity
• Forgetfulness
• Inability to pay for medication

Question 19

What are some examples of Perceptual factors that might get in the way of adherance?

Answer 19

• Reasons for needing medication
• Efficacy of supposed treatment
• Concerns about SEs
• Relationship with HCP

Question 20

How does the PAPA flow chart work?

Answer 20

• Beliefs about Illness and Medication make up the Perceptions about the illness
• If these line up then the patient has Intent to take medication
• Next step is whether they are able to use medication
• If yes then Adherence

Essentially claims that Perceptions create Intent, which leads to Adherence unless Practicalities get in the way

Question 21

What is the COM-B model of behaviour?

Answer 21

• Capability, Opportunity and Motivation all influence behaviour
• All also influence each other
• Capability = “psychological and physical capacity to engage in a behaviour”
• Opportunity = “all factors lying outside of the individual that make a behaviour more or less likely”
• Motivation = “all brain processes that energise and direct behaviour”

Question 22

What are some factors that fall into capability in COM-B?

Answer 22

Psych:

• Comprehension of disease and treatment
• Cognitive functioning
• Executive function

Physical:

• Strength
• Dexterity

Question 23

What are some factors that fall into motivation in COM-B?

Answer 23

Reflective (relating to evaluation and plans)

• Perception of illness
• Beliefs about treatment
• Outcome expectancies
• Self-efficacy

Automatic (relating to more immediate situation)

• Mood
• Stimuli/ Cues
• Habits

Question 24

What are some factors that fall into opportunity in COM-B?

Answer 24

Physical:

• Cost
• Access
• Packaging
• Regimen complexity

Social:

• Stigma of disease
• Social support
• Patient-doctor relationship
• Religious or cultural beliefs

Question 25

What factors did Howard Lowenthal suggest influenced how a patient perceives their disease?

Answer 25

ILLNESS PERCEPTIONS: - Identity (what is this and what symptoms are associated with this) - Timeline (how long will this last, is this something that will come and go) - Consequences (what does this mean for me, for my family) - Cause (what made this happen) - Control/Cure (what can I do? will this work) IT CCCC

Question 26

What are the key beliefs that affect adherence?

Answer 26

- Beliefs about the illness (identity, consequences, timeline, control/cure, cause) - Beliefs about the treatment (includes both beliefs about medicine as a whole and this specific form of treatment (necessity and concerns)

Question 27

According to the Necessity-Concerns Framework, what influences how a patient feels about a prescribed medication?

Answer 27

- Beliefs they have about how necessary this prescribed medication is for their health (NECESSITIES) - Beliefs about potential negative effects (CONCERNS) Combine to make up the complex image of a patient's specific beliefs around a medication

Question 28

What evidence is there to support the Necessity-Concerns Framework?

Answer 28

Horne et al (2013): - Meta-analysis of NCF and NA - 94 studies - Found higher adherence was associated with; increased necessity beliefs, decreased concern beliefs - Good evidence for NCF as a predictive framework for adherence - Study also showed that many patients who have high need and concern beliefs, these will often take the medication but at a lower dose (again, logical to them but perhaps not us)

Question 29

What effects can sensations of personal control and emotional response have on adherence?

Answer 29

Both can have either positive or negative effects on adherence, depending on the person.

Question 30

What is the INAS and what was it developed for?

Answer 30

- International Non-Adherence Scale. - Works off the NCF, but accepts that this doesn't explain 100% of NA and therefore expands on it by focusing on IDENTITY - Works on the idea that some patients reject the identity associated with the illness, prioritise maintaining normality above all else - Choose not to adhere as treatment is a reminder of their condition

Question 31

Outline the Health Belief Model (Rosenstock, 1974):

Answer 31

- Demographic and Psychological characteristics affect... - Health motivation, Perceived threat and Assessment of risk vs benefit - All of which affect Action - Perceived threat = how a patient thinks of their susceptibility and severity - Risk vs Benefit assessment looks at perceived benefits and perceived barriers

Question 32

What criticisms have been made about the Health Belief Model and Theory of Planned Behaviour?

Answer 32

Too rational, imply humans make their decisions on a pro/con basis when in fact we are for more emotional than that

Question 33

Outline the Theory of Planned Behaviour?

Answer 33

- Attitudes, Subjective Norms and Perceived Control affect... - Behavioural Intent, which then affects - Behaviour However, we are unclear what lies between behavioural intent and actually performing the behaviour, only what drives intent.

Question 34

When does HBM say an action is likely to occur?

Answer 34

- Perceived threat is high - Benefits outweigh barriers - Cues in place

Question 35

When does TPB say an action is likely to occur?

Answer 35

- People important to you support the behaviour (norms) - Behaviour is considered positive (attitudes) - Confidence to perform behaviour is high (perceived control)

Question 36

Broadly, what are the two things we can do to improve adherence?

Answer 36

- Use the consultation to anticipate and plan | - Incorporate specialist interventions

Question 37

What can be done in the consultation to improve adherence?

Answer 37

- Check patient understanding of treatment - Provide clear rationale for NECESSITY - Elicit and address any CONCERNS - Agree a practical plan for how, where and when to take treatment - Identify any possible facilitators and barriers

Question 38

What are the NICE recommendations for changing a behaviour?

Answer 38

- Goals and Planning: Agree goals, develop action plan, develop coping plans - Feedback and Monitoring: Encourage self-monitoring of behaviour and outcome, provide feedback on behaviour and outcome - Social support: Friends, relatives, colleagues, buddies to provide practical help, emotional support, praise, reward

Question 39

What specialised interventions exist to try and boost adherence?

Answer 39

- Specialised intervention programmes - Text/phone/web based - Targeting of patient beliefs

Question 40

What did the Petrie et al (2012) study show about specialist adherence interventions in asthma?

Answer 40

- Identified 216 patients with, aged 16-45 with low levels of adherence - Given baseline assessment - Half sent into normal care half received tailored text messages - Text messages targeted the specific reason for the patient's NA e.g. if they believe they don't need to use it when they don't have symptoms they'll receive a text saying your asthma is always present - Adherence measured by phone calls at 6 weekly intervals initially then at 6 and 9 months - A measured as puffs taken/ puffs prescribed - 80%+ is considered adherent Findings: - Significant positive change in illness perceptions and treatment beliefs - Perceived duration of asthma increased - Perceived control increased - Perceived necessity of treatment increased - Adherence remained high at 6 and 9 months

Question 41

What did the Bushnell et al (2010) study show about adherence in stroke patients?

Answer 41

- Performed as 25% of patients discontinue a medication within 3 months - Cognitive impairments common post-stroke - Mix of UI and I NA - Selected patients with sub-optimal A 3 months post first incident of stroke/TIA - Gave them two sessions; 1 targetting how best to make sure they take them e.g. with action plans stuck on bathroom mirror (UI NA), and 1 session targeting beliefs about condition, necessity and concerns around meds (I NA) - Adherence measured using MEMS (looked at % of pills taken, days with correct pill number taken and how close to agreed upon time the pills were taken) - Found both beliefs and adherence had improved by end of study - Suggests there is a role for specialist intervention targeting UI and I NA in those who struggle to adhere to therapy.