7. Adherence to Treatment_slides - Tagged.pdf

Genes, Behaviour and Environment 4MBBS103 Neuroscience, Behaviour and Social Science Adherence to treatment Learning objectives 1. Explain the meaning and extent of non- adherence in healthcare 2. Outline the difference between unintentional and intentional non- adherence 3. Describe...

Genes, Behaviour and Environment 4MBBS103 Neuroscience, Behaviour and Social Science Adherence to treatment Learning objectives 1. Explain the meaning and extent of non- adherence in healthcare 2. Outline the difference between unintentional and intentional non- adherence 3. Describe determinants of non-adherence 4. Psychological interventions used to improve non-adherence Objective 1 Explain the meaning and extent of non-adherence in healthcare Definition The extent to which a person’s behaviour – taking medication, of non- following a diet, and/or adherence executing lifestyle changes, corresponds with agreed recommendations from a health care provider. World Health Organisation 2003 Terminolog Compliance y Concordance Adherence Treatment may include Taking prescribed medications, daily, with/without food, tablets and injections. Attending follow-up outpatient appointments Lifestyle changes - Diet, exercise, stress reduction Monitoring tests Blood tests, x-rays, sight tests, Extent of the problem A number of reviews have identified non-adherence to medication to be common (NCCSDO, 2005) WHO (2003) report on non-adherence: Estimated that over 30 -50% medicines prescribed for long term illnesses are not taken as directed Highest for preventive or lifestyle behaviours Lowest for serious illnesses Royal College of Pharmacy (2013): £300 million per year wasted on medicines because of non- adherence Medication adherence Stroke ~ 25% HIV ~50% Kidney disease 30-70% 30-50% of patients Heart disease with LTC’s are non- Type 2 diabetes adherent to - Oral medications 15-45% treatment -insulin 40% MS 25% Asthma 50-60% Measuring Adherence Self report questionnaire Self monitoring (diary) Pill counts Frequency of dispensing (pharmacy data) Mechanical measures (microchips in bottle tops, etc) Biochem indicators (blood or urine levels of drug) Proxy measure (Clinical or other outcome symptoms,)  Non-adherence – why Mortality post MI does it matter? Non-adherence can lead to disease progression or delayed recovery, more complications and increased morbidity/mortality, more hospitalisations. “Better adherence results in better clinical outcomes” DiMatteo (2002) Personal costs: increased disability/decreased quality of life. Patient may have to retire early, rely on a carer etc Societal costs: higher healthcare costs, more aggressive treatment, benefit payments. Ho PM et al. Impact of medication therapy discontinuation on mortality after myocardial infarction. Archives of Internal Medicine, 2006.  Impact of adherence “Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments“* (Haynes et al., 2002) Haynes, R., McDonald, H., Garg, A., & Montague, P. (2002) Interventions for helping patients to follow prescriptions for medications. The Cochrane Database of systematic Reviews, 2, CD000011  Case study- Asthma Very significant increase in prevalence, morbidity, and mortality over last 30 years 5.4 million people in the UK are currently being treated for asthma (1:12 adults)* Major costs to the individual and to health care services Treatment: Shift in emphasis from symptom relief prevention While reliever treatment is immediate in its effect, the anti-inflammatory effect of preventer (steroid) is delayed and less easily perceived. *https://www.asthma.org.uk Asthma inhaler treatment Reliever inhaler Preventer inhaler  Recognising asthma (symptoms/label) Monitoring symptoms & severity What does Avoiding trigger factors Managing acute attacks adherence Attending follow-up appointments and self- Collecting further supplies Correct inhaler use: Reliever and Preventer manageme Taking optimal medication nt mean in asthma? NB: Consistent evidence of low adherence (especially for preventer medication) - typically adherence rates found = 50-60% Objective 2 Outline the difference between unintentional and intentional non-adherence Categories of non-adherence Unintenti Intention onal non- al non- adherenc adherenc e e Unintentional non-adherence Practical barriers Capacity/ Resource functional limitations limitations Unintenti onal non- adherenc e Unintentional non-adherence “I couldn’t work the inhaler” asthma treatment “I sometimes forget to pick up “I try to take my inhaler every day my next pack from the pharmacy” but I find it hard to remember” “I thought I was supposed to be taking it only when “I couldn’t get to the pharmacy to My breathing was bad – not all the time” collect my inhaler” Are patients rebelling against recommended advice? Intentional non- adherence Making a decision not to take all of the doses as Intention prescribed – or take too much or at the wrong time. al non- The decision can be based on a number of factors but will be logical “common sense” to adherenc the patient e The decision can change over time depending on several factors e.g. symptoms, health education, social influence, experience etc Objective 3 Describe determinants of non-adherence Intentional non-adherence - Perceptual barriers Negative emotion Illness Social Perceptions support Motivation Treatment Perceptions Relationship with HCP Intentional NB: The terms illness non- perceptions, beliefs, Socio-demographic factors adherence cognitions, cognitive poor predictors of non- components are often used interchangeably adherence. Intentional non-adherence - models Illness Representation Appraisal of (e.g., timeline, cause, Coping behaviour consequences) outcome Stimuli Emotional Appraisal of representation (e.g., Coping behaviour outcome fear, anxiety) Common sense model of illness What is this? What symptoms are Identity associated with this? Cause What made this happen? Illness How long will this last? Timeline Is this something that comes and goes? perceptions What does this mean for me? Consequences And my family? What can I do? Cure and Control How well does the medicine work? Necessity How much do I need this medicine? Treatment perceptions What are the potential problems of taking Concerns this medicine? Beliefs about Medicines Questionnaire (BMQ) Specific beliefs about medicines prescribed for a particular illness General beliefs about medicines as a whole – pharmaceuticals as a class of treatment Horne, R., Weinman, J. and Hankins, M. (1999) The Beliefs about Medicines Questionnaire : Balance of treatment beliefs and risk of non-adherence High concerns Sceptical Ambivalent Low necessity High necessity Risk of non- adherence Indifferent Accepting High Med Low Low concerns Mann (2009) J Behav Med;32:278-284 27 Representations of illness and treatment- a question of fit  Case study- Asthma - Research Cross sectional study, N=100 primary care patients (Horne & Weinman, 2002) Self report measures of illness perceptions, treatment beliefs and adherence Treatment beliefs were the strongest predictors of adherence Stronger necessity beliefs = higher adherence Weaker concerns = higher adherence Illness perceptions related to treatment beliefs Stronger belief that asthma is a chronic condition= stronger beliefs in the necessity of preventer medication Findings have been replicated (Emilsson et al., 2011) Intentional non-adherence “They make me put on asthma treatment weight” “It is a pain having to use my inhaler twice a day, every day - it reminds me I’m ill…” “I don’t want to take “I don’t have any steroids – they ‘re bad problems with my for you..” breathing or my asthma at the moment - I don’t need to take my “I don’t think preventer inhaler preventer medication” medication is very powerful anyway -how do I know it is working – I don’t need to take it” he Necessity-Concerns Framework CONCERNS About potential adverse effects Doubts about personal NECESSITY of medication META-ANALYSIS1 94 studies covering 25,072 patients across 18 countries 24 different long-term conditions Necessity OR = 1.742, p < 0.0001 [CI 1.569-1.934] Concerns OR = 0.502, p < 0.0001 [0.45-0.56] Horne, R., Chapman, S.C.E., Forbes, A., Parham, R., Freemantle, N. & Cooper, V. (2013). Understanding patients' adherence-related beliefs about prescribed medicines: a meta-analytic review of the Necessity-Concerns Framework. PLoSONE, 8(12): e80633. Doi:10.1371/journal.pone.0080633. Other determinants Psychosocial factors – social and family support (Grenard 2011) Disease/Healthcare factors – treatment regimen, practical barriers Communication poor practitioner- patient communication Objective 4 Psychological interventions used to improve non-adherence Myth: Adherence can easily be fixed by…. Providing information Providing reminders Being authoritative Fear arousal HEALTH CARE SYSTEM POLICY & PRACTICE PATIENT-PROVIDER INTERACTIONS PATIENT INTERVENTIONS Medicines optimisation NICE (2015) released medicines optimisation guidelines to promote medication adherence Applied psychology to: Medication reviews Self-management plans Patient centred care supplemented with use Source: Royal Pharmaceutical Society (2013) of decision aids 36 “Information alone does not change behaviour” Beakelman, D. (1990) Strategies for improving adherence Specific action plans or implementation intentions Electronic reminders Smartphone apps Medication monitors Many interventions are not successful or only produce modest improvements (Nieuwlaat, 2014) Improving adherence Removing barriers (Unintentional) Repeat prescription, financial, social Improving communication Knowledge, memory, instruction Identifying maladaptive illness and treatment perceptions and modifying them (Intentional) E.g. symptoms, timeline, consequences, drug concerns  Targeted texting based on individual belief profile Non-Adherent profile Timeline Your Yourpreventer Personal control isAsthma safe to is take every day present Unsubscribe even when txt Treatment control STOP you don’t have Identity symptoms Consequences Medication necessity Medication concerns 0 10 20 30 40 50 60 70 80 90 100 n=216, RCT, texts sent over 18 weeks. Petrie, K. J., Perry, K., Broadbent, E., & Weinman, J. (2012). A text message programme designed to modify patients’ illness and treatment beliefs improves self ‐reported adherence to asthma preventer medication. British journal of health psychology, 17(1), 74-84.2 Atlantis Healthcare | Commercial in Confidence 39 Intervention tailored to beliefs Mean self reported adherence: 57.8% versus 43.2% in control Percentage taking over 80% of Rx dose: 37.7% versus 23.9% Significant positive change in illness perceptions and treatments beliefs versus control group Increase in perceived necessity Increased perceived control of Asthma Increased perceived duration of Asthma Behaviour and belief changes sustained beyond the life of the intervention. © 2012 Atlantis Healthcare | Commercial in Confidence 40 https://www.asthma.org.uk/globalassets/health-advice/adult-asthma-action-plan.pdf 41 Threatening health risk communication Self-affirmation interventions People are motivated to maintain a global sense of self-worth. Health risk information might be rejected if threatening to self Self-affirming manipulations reduce resistance to information Can it work in long-term conditions? People as active decision- makers Healthcare providers have a duty to help patients make treatment decisions that are informed by an accurate understanding of the likely benefits and risks of treatment... rather than by mistaken beliefs about their illness and the treatment Informing should be an active process. It is not just presenting the facts or dictating “must-dos”. Consider a patient’s beliefs and whether beliefs are a barrier to an unbiased interpretation of the evidence Normalising non-adherence ◦ “A lot of people have trouble taking their medications regularly” Establishing specific difficulties ◦ “Do you find it more difficult to remember at weekends or when you’re on holiday?” “Do you experience any side effects? How have you coped with them?” Check knowledge of the medication regimen ◦ “Do you have a routine for taking your medication?” Improving Adherence Summary Anticipate non-adherence (normalise) Understand beliefs about treatment & expectations Check unintentional barriers to adherence Memory cues can help – “take with food” Medicine organisers and text reminders The doctor patient relationship is very important - shared collaborative decision making. The quality of the communication will impact on memory and satisfaction 46 Simple, well-organised information is better recalled Summary If you prescribe a medication many people will not take it. Explore unintentional and deliberate non-adherence Focus on illness and treatment beliefs to understand non-adherence Draw on motivational and behaviour change skills from previous lectures to improve medication adherence  According to the World Health Organisation, approximately what percent of patients fail to take their prescriptions as prescribed by their doctors? Quick quiz 1Q A: 10% B: 25% C: 50% D: 80%  According to the World Health Organisation, approximately what percent of patients fail to take their prescriptions as prescribed by their doctors? Quick quiz 1A A: 10% B: 25% C: 50% D: 80%  Sarah has been in remission from breast cancer for 1 year. She has been prescribed tamoxifen for 5 years to reduce the risk of recurrence. Sarah has discontinued her medication as she finds the side-effects of the drug Quick difficult to manage. What is this behaviour described as? quiz 2Q A: Non-compliance B: Non-persistence C: Intentional non-adherence D: Unintentional non-adherence E: Poor necessity beliefs  Sarah has been in remission from breast cancer for 1 year. She has been prescribed tamoxifen for 5 years to reduce the risk of recurrence. Sarah has discontinued her medication as she finds the side-effects of the drug Quick difficult to manage. What is this behaviour described as? quiz 2A A: Non-compliance B: Non-persistence C: Intentional non-adherence D: Unintentional non-adherence E: Poor necessity beliefs  A patient who sometimes experiences severe asthma attacks is prescribed a preventer inhaler to reduce their risk of attacks. Though the inhaler is prescribed daily the patient only uses it when they are feeling unwell. What should the health care professional do Quick to try to improve adherence? quiz 3Q A: Provide information about the severity of their asthma B: Provide reminders to use the inhaler C: Discuss their level of social support D: Discuss their resource limitations E: Discuss their treatment perceptions  A patient who sometimes experiences severe asthma attacks is prescribed a preventer inhaler to reduce their risk of attacks. Though the inhaler is prescribed daily the patient only uses it when they are feeling unwell. What should the health care professional do Quick to try to improve adherence? quiz 3A A: Provide information about the severity of their asthma B: Provide reminders to use the inhaler C: Discuss their level of social support D: Discuss their resource limitations E: Discuss their treatment perceptions Reading Ayers, S., & De Visser, R. (2017). Psychology for medicine and healthcare. Sage. Ogden, J. (2012). Health psychology: A textbook: A textbook. McGraw-Hill Education (UK). Useful references Ayers, S., & De Visser, R. (2017). Psychology for medicine and healthcare. Sage. Horne, R., Weinman, J., Barber, N., Elliott, R., Morgan, M., Cribb, A., & Kellar, I. (2005). Concordance, adherence and compliance in medicine taking. London: NCCSDO, 2005, 40-6. Horne, R. & Clatworthy, J. (2010) Adherence to Advice and Treatment. In D. French, K. Vedhara, A. A. Kaptein, & J. Weinman (Eds.), Health Psychology (2nd edition) (pp. 175-188). Oxford: Horne, R., Chapman, S. C. E., Parham, R., Freemantle, N., Forbes, A. & Cooper, V. (2013) Understanding patients’ adherence- related beliefs about medicines prescribed for Long Term Conditions: A meta-analytic review of the Necessity-Concerns Framework. PLOS One, 8(12), e80633. Hughes, L. D. (2013) Looking at the psychology behind non-adherence can assist with management of patients with RA. Guidelines in Practice, 16(12), 48-50 Kripalani S., Yao X. & Haynes R. B. (2007) Interventions to enhance medication adherence in chronic medical conditions. A systematic review. Arch Inter Med, 167, 540-550