Download Health Psychology

Health Psychology
Adherence
Requirements
Why we don’t
 Measuring
 Improving
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Use the first 4 or last 3 studies
Background
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ADHERENCE
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CUSTOMISING
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Personal choice or little influence over what is happening. More they
feel in control more likely to adhere.
SELF-EFFICACY
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Choosing not to comply – may not have a belief in the benefits,
treatment causes suffering, confusion, practical barriers (cost), is illness
still there when medication isn’t
LOCUS OF CONTORL
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Follow advice reasonably closely but make an attempt to get it to fit with
lifestyle
RATIONAL NON-ADHERENCE
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Adherence rates requiring medicine for long or short term illness =
60%. But if a diet or exercise/lifestyle change needed compliance is
lower.
A belief they will be successful in what they do and given the means to
be capable too.
DOCTORS AS PATIENTS
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Shouldn’t self prescribe but 70% do. Shouldn’t treat family members –
80% do
Background 2
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TYPES OF REQUEST
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Short term adherence (3x a day for 3 weeks); lifestyle
(eat more fruit); stop (stop smoking); long term regime
(diabetic diet, renal dialysis)
MEASUREMENT
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Self report – ask. Patients overestimate
Therapy outcome – getting better. Other factors may
affect
Health worker estimates – unreliable
Pill count – how many thrown away? Random raid?
Mechanical method – devices on bottle; measure how
many taken out, but not how many taken
Biochemical test – blood/urine test
Background 3
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IMPROVING
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PRESENTATION
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Structured/categorised information easier to remember
Primacy effect
Repetition does not improve recall
Some medical knowledge helps
TECHNICALITIES
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Simple verbal instructions
Specific not general
Smaller steps
Key information emphasised
Simple written
Repeat in own words
MEMORY
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Old people have different understanding and can’t follow complex instructions
Containers are difficult
Large ranges of treatment increase side-effects
Baffle and intimidate
If not understood or recalled then unlikely to adhere
DOT
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Direct observation of patient taking medication
3 Short Summaries
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We don’t always do as we are told by health workers (or
mothers). At first glance this appears to be lazy or even
reckless, but careful closer consideration shows many health
choices we make are a common-sense way of dealing with
the many influences on us
Measuring behaviour is difficult at the best of times.
Measuring behaviour such as treatment adherence, often
done in private, is even more difficult. The various methods
used, however, probably give a fair idea of how much people
follow medical advice.
People can be encouraged to be more adherent through a
variety of methods. The more successful ones include
improving available information, watching people take the
medicine, and threatening with prison.
Adherence – Study 1
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Sethi et al
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Who
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What
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2003
Drug adherence to antiviral therapy & resistance
Correlation, longitudinal
195, 32-48yrs, HIV Moor clinic – restricted cluster (criteria met –
drugs prescribed, low HIV load, no drug mutations, no viral failure)
Paid & informed
Visit following clinic appointments
Cumulative adherence measured using formula (prescribed –
missed / prescribed) and categorised
HIV load tested – independent, experienced, blind tester – if
greater than 500 loads then resistance
Results
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14% developed resistance
66% no resistance; 19% not followed up (death, prison,
discontinuation, attrition, transfer)
Cumulative adherence 70-89& shows significance with resistance
to drugs. Outside this range no correlation with resistance. Bell
shaped distribution of adherence and drug-resistance
Adherence – Study 2
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Yung
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Who
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What
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1998
Age and knowledge and relationship with adherence
56 men, 70 women, 50-82 years, diabetic, clinic, HK, cluster sample. Natural
experiment
7 weeks informed consent, interviewed by 1/3 pharmacy studnets under supervision
½ doctors.
Data includes age, sex, duration of & treatment, attendance at classes, presence of
complications, attacks, other conditions, blood glucose, renal, liver function tests.
2 validate questionnaires. 1 – knowledge of conditions and adherence – what is
wrong with your blood glucose, what do the tablets d, meals, miss meal, too many,
dizzy, card carried, attack, sweets, relatives. 2 – measure knowledge of symptoms
of attack – yes, no, don’t know, list given
Read if illiterate/visually impaired, care not to ask leading questions
More correct answers = greater knowledge/adherence
Results
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Significant decline in correct answers given to knowledge as age increased, but only
to half of adherence questions. Significant decline in knowledge of symptoms with
age (except tingling lips)
Previous experience of attack had no effect on knowledge
If never attended classes then scored lower on all variables (knowledge of diabetes,
knowledge of attacks, adherence)
More recent attendance correlated higher scores
Adherence – Study 3
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Watt et al
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Who
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What
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2003
Funhaler – asthma made fun
Experiment
10 boys, 22 girls, mean age 3.2y
All prescribed drugs via inhaler
Informed consent from parents
Standard inhaler in week 1. Funhaler week 2 (toys, spinner,
whistle – distracts and reinforces correct delivery, doesn’t interfere,
can be replaced if bored)
Adherence measured via parents questionnaire frequency and
regularity of use
Results
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27/32 completed questionnaires. 38% administered Funhaler more
regularly, 60% more children took recommended cycles
Adherence – Study 4
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Sharma
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Who
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What
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2003
Adherence to food pyramid by ethnic groups
Natural experiment, 115000 people 45-75y, ethnic groups (American,
Japanese American, Hawaiian) quota sample, informed consent
Questionnaire – food frequency questionnaire, standardised before use
Self administered postal. Asks how often foodstuffs eaten over 3 days,
covered 85% intake of fat, fibre, vitamin A, carotenoids, vitamin C, measured
in servings and converted to calories. Traditional foods to ethnic groups
covered even if nutritional value not relevant
Results
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Data for each group compared to recommended intake. Little variation
between ethnic groups and adherence – no one adhered more than any other
group. If calorie intake below 1600 per day (regardless of ethnicity) then food
groups missed out (usually dairy) 58% of time. If calorie intake above 2800
(no ethnicity associated) then 3x alcohol, more fat and added sugar
Between groups – Hawaiians had highest daily calorie intake and high BMI,
ate most daily servings of food groups with exception of dairy. JapaneseAmericans had low BMI but the men ate 2 more servings per day of grain than
white men.
Study 5
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DiMatteo
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Who
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What
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2000
Depression is risk factor for non-compliance
25 studies, 68-98, 12 about depression, 13 about anxiety
Studies measure adherence and depression/anxiety but
not being treated for depression/anxiety – reviewed
results
Results
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No correlation between anxiety and non-adherence but
strong correlation between depression and non-adherence
Compared with non-depressed patients, depressed
patients are 3x more likely to fail to adhere
Study 6
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Choo et al
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Who
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What
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2001
Risk factors for over-reporting adherence
286 (age 18-84, 50% female, 33% black, 67% graduate) on antihypertensive therapy
Baseline questionnaire – socio-economic status, medication,
adherence, health beliefs, health status, social support.
3 months monitoring – adherence question – while using special
bottle how many days in average week did you forget to take a
pill? Actual adherence measured by electronic monitoring vial.
Informed about purpose of electronic medication monitor
Results
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21% admitted missing 1 or more days a week – but true figure
42%. Over-reporters tended to be from lower socio-economic
background, lower health risk, and taking more than one daily
dose
Study 7
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Lustman
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Who
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What
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2000
Depression in diabetes
Treat depression and see if adherence improves
60 patients diabetic and major depression; advertisement
2 centres (screened out suicidal, bipolar, psychotic)
Randomly assigned 2 groups. 1 – received antidepressive
drug other placebo. Double blind. Over 8 weeks daily
dose of antidepressive given and depression measured (2
known scales). Blood sugar monitored as a measure of
adherence to medical regimen
If still depressed after 8 weeks referred for therapy
Results
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Antidepressive patients less depressed and showed
healthier blood sugar levels
General Review
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Ethics
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Reliability/Validity
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Validity – measure what we think we are
Reliability – able to measure it consistently
Sethi – straightforward but face validity (no predictive validity)
Sampling
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Maintain confidentiality, informed consent, withdrawal rights, harm minimised etc
Sharma & Watt some withdrawal seen
All informed (parental in Watt)
Minimised harm – Funhaler designed to deliver drugs without affect
Sethi & Yung, identified non-adherence factors but did nothing about it!
Sharma – very large numbers involved, so ethnic groups well represented
Sethi – what if a different drug was used? Or a different medical condition
May limit ability to generalise but also allows us to discuss factors
Usefulness
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Reveal why people do not adhere – therefore improve adherence
Sharma – adherence to diet to develop programs for obesity
Different groups require different approaches
Need to be fun – Watt
Cognitive memory aids needed - Yung
Questions
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Describe one study of why people do not adhere to medical
advice (6)
Evaluate research into non-adherence to medical advice (10)
Describe one way of measuring adherence/non-adherence
(6)
Discuss validity of measures of adherence/non-adherence
(10)
Describe one way of improving adherence (6)
Discuss problems of improving adherence (10)
Describe what psychologists have found out about why
people do not follow medical advice (10)
Discuss the psychological evidence on the reasons why
people do not follow medical advice (16)
Suggest one technique that could be used to encourage
children to use their asthma inhalers more regularly. Give
reasons for your answer (8)