Health Psychology & Human Diversity.pdf

Health Psychology & Human Diversity Compliance, Adherence & Concordance Offered by: Dr. Kareem Nasir Hussain Al- Esawi F.I.C.M.S, C.A.BM.M.R.C.PSYCH Consultant psychiatriste Edited by: Muntadher Abdulhussein Ameer Ghazi Compliance / ad...

Health Psychology & Human Diversity Compliance, Adherence & Concordance Offered by: Dr. Kareem Nasir Hussain Al- Esawi F.I.C.M.S, C.A.BM.M.R.C.PSYCH Consultant psychiatriste Edited by: Muntadher Abdulhussein Ameer Ghazi Compliance / adherence Compliance(Doctor center) – extent to which the patient complies with medical advice – patient doing what they are told, doctor knows best,powerful doctor/passive patient Adherence –extent to which patient behaviour coincides with medical advice – Attempt to be more patient-centred, need for agreement, patient right to choose  Extent of the problem of non-adherence Non-adherence to medical advice is the norm Chronic illness – 30-50% non-adherent – 10-25% of all hospital admissions due to non-adherence (Ley, 1997) DiMatteo (2004a) reviewed 733 studies over 50 years and found average rate of non-adherence 24.8% Changes in life style have very low adherence rates (Cluss & Epstein, 1985)  Non adherence across disease types Non-adherence common even in more severe disease – even transplant patients (Wainwright & Gould, 1997) – e.g. Greenstein & Siegel (1998): 22% of adult renal transplant patients are non-adherent to immunosuppressant medications. – Rovelli (1989): 91% of non-adherent patients experienced organ rejection or death, compared to 18% of adherent patients Highest rates of adherence found in HIV disease, arthritis, GI disorders and cancer. Lowest in pulmonary disease, diabetes and sleep disorders (DiMatteo, 2004a) The impact of non-adherence Impact on patients’ health financial implications lots of research, little progress made in reducing rates of non-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) Problems with measuring adherence Treatment not usually a ‘on-off’ event, usually continues over a period of time What ‘counts’ as adherent – every item of medication exactly as prescribed? Hard to compare studies for different conditions with different medication or treatments Lack of consistency in measures  Indirect measures Patient self-report: – Advantages: easy to obtain, inexpensive – Disadvantages: prone to inaccuracies / bias, tendency to over-report adherence Ley (1988) 78% patients reported compliance. More objective measures suggest this figure should be in the region of 46% Second-hand reports (from doctors, carers etc.): – Similar advantages and disadvantages to patient reports – Also depends on familiarity with patient Ley (1988) found a correlation of only 0.21 between doctors’ ratings of patient adherence and other measures of compliance  Indirect measures Pill counts: – more objective than self / other-reports, but still subject to inaccuracy (e.g., lost pills) Mechanical or electronic measures of dose e.g. record time at which container is opened: – Advantages: objectively measures whether a dose has been dispensed, more accurate than other indirect measures – Disadvantages: doesn’t measure whether medication has actually been taken  Direct measures Urine or blood test: – Advantages: provides most direct measure of consumption / adherence – Disadvantages: expensive, limited to use in clinical practice, invasive, ?affected by metabolism, non- adherence may still be masked (e.g., can take medicine but not as prescribed, just before attending surgery perhaps) Observation (e.g., of consumption): – Similar problems to above Why don’t patients adhere to medical advice or treatment? - expensive Lack of information -side Ley’s cognitive hypothesis model of compliance (1988) Understanding Satisfaction Compliance Memory  Patient satisfaction Ley (1988) reviewed extent of patient satisfaction with consultation: – 21 studies of hospital patients: 41% were dissatisfied with treatment & 28% of GP patients were dissatisfied Satisfaction stems from various aspects of consultation: – Affective aspects (emotional support, understanding), behavioural aspects (appropriateness of referral, diagnosis), competence of health professional (Ley, 1988)  Patient understanding Extent to which patients understand the content of the consultation Boyle (1970): only 85% correctly defined arthritis, 77% jaundice, 52% palpitations, 80% bronchitis; only 42% correctly located the heart, 20% the stomach & 49% the liver Lack of understanding about illness, particular organs & treatment regimes is likely to affect compliance with advice (Ley, 1988)  Patient recall Bain (1977): after GP consultation 37% couldn’t recall name of drug, 23% couldn’t recall the frequency of dose, 25% couldn’t recall duration of treatment Recall is influenced by many factors: – Anxiety, medical knowledge, intellectual level, importance of the statement, primacy effect, number of statements increase recall (Ley, 1988) Ley’s model: implications for improving compliance Improve communication – Simplify any information given – Use repetition – Be specific – Primacy and Recency effect: patients tend to remember the first thing and last things they were told – Written information and instructions Emphasise the importance of compliance Follow-up consultation with additional interviews/consultations  Criticisms / limitations of Ley’s model Role of information to correct deficits? – If patients just understood why they should comply, and how to comply, they would?? – Info essential for adherence, but enhancing knowledge does not necessarily lead to adherence – Paternalistic? Social context, psychological factors, treatment characteristics But was (& still is) very influential Social setting & adherence Meichenbaum & Turk (1987) The medical consultation takes place in a social setting, not in isolation Organisational setting – pleasant waiting rooms, good links between inpatient & outpatient services, personalised care, positive attitudes from health professionals towards treatment, regular follow-up  Social factors & adherence Social /familial support – patients with little social support or experiencing social isolation are less likely to adhere – Social support (especially practical support) associated with higher adherence (DiMatteo, 2004b) – patients in cohesive families 1.74 times more likely to be adherent (DiMatteo, 2004b) – Individuals from unstable families are less adherent (Bender et al, 1998) – Homelessness was only predictor of non-completion of therapy in tuberculosis outpatient clinic (Brainard et al, 1997) Individual/psychological factors & adherence Hulka (1979): no significant relationship between age, sex, marital status, education, number of people in household, social class & adherence Limited progress in identifying the “non- compliant personality” But cognitive deficits or psychological problems impact on compliance (Christiannse et al, 1989) – e.g. depressed patients x 3 less likely to adhere to medication for chronic illness (DiMatteo, Lepper, and Croghan, 2000). Treatment factors & adherence Preparation for treatment: – treatment setting, waiting time, timing of referral, inconvenience,poor reputation Immediate character of treatment: – characteristics of treatment recommendations, complexity of regime, duration of regime, degree of behaviour change, inconvenience, expense, inadequate labels, awkward container design Treatment factors & adherence (Meichenbaum & Turk, 1987) Administration of treatment: – inadequate supervision by professionals, absence of continuity of care, failure of parents to supervise drug administration Consequences of treatment: – medication side effects, social side effects, stigma  Doctor-patient interaction & adherence More patients comply if physician is warm, caring, friendly & interested (DiMatteo & DiNicola, 1982) Perceived interpersonal competence (social conversation, better communication, more information) & more technical competence increase adherence (Hall et al, 1988) Positive behaviours: good eye contact, smile, lean towards the patient increase adherence Patients’ beliefs: Health Belief Model Cognitive model used to explain compliance with medical recommendations (Becker & Mainman, 1975) The more a prescribed medication accords with a patient’s belief system, the more likely they are to comply Extent of adherence depends on: – perceived disease severity – perceived susceptibility to disease – benefits of treatment recommended – barriers to following treatment Patients’ beliefs Horne et al 2005) Beliefs about illness – e.g. severity, interpretation of lack of symptoms, understanding of illness as chronic vs episodic Beliefs about risks and benefits of medication – necessity, harmful effects (side effects, addiction) Alternative resources Conflict with other activities e.g. alcohol (‎ Patients’ beliefs Patients often reject or actively modify treatment or advice based on their beliefs and priorities e.g. Type II diagnosis – management of symptoms not chronic illness; sense of control – “Life doesn't have to be as rigid as the dietician tells you….All I keep doing is I keep adjusting my targets to meet my bodily conditions. If I suddenly start feeling poorly badly I bring [food and alcohol intake] down again.” Murphy & Kinmonth (1995, p187)  Unintentional non-adherence – arises from capacity and resource limitations that prevent patients from following treatment recommendations ; may be individual constraints (e.g. memory, dexterity) and/or aspects of their environment (e.g. problems of accessing prescriptions, competing demands) Intentional non-adherence – arises from the beliefs, attitudes and expectations that influence patients’ motivation to begin and persist with the treatment regimen Horne et al (2005) Concordance Concordance – negotiation between patient & doctor over treatment regimes – patients beliefs and priorities are respected – patient is active, can make decisions in partnership with doctor Concordance does not refer to patient’s medicine-taking behaviour, but the nature of the interaction between clinician and patient Concordance & adherence Achieving concordance argued to lead to better adherence because: – Patient involved in, and has shared ownership of, decisions about treatment – Patients’ beliefs, expectations, lifestyl e, and priorities can be taken into account – Barriers to adherence (e.g. practical or informational) can be addressed – Promotes patient trust and satisfaction with care which make adherence more likely  Towards concordance in prescribing Elwyn et al (2003) Define problem: clearly specify problem taking in your own & patient’s views Convey equipoise: make clear there may not be set opinions about which treatment is best For him Describe treatment options, and consequences of no treatment Provide information in preferred format (e.g. written) Check patient understanding of options  Towards concordance in prescribing Elicit patient’s concerns & expectations about condition, possible treatments & outcomes Ascertain patient’s preferred role in decision making Defer if necessary: review needs & preferences after patient has had time for consideration, with family/friends, if they wish Review decisions after specified time period  Tensions in concordance does not address medication-taking tensions between evidence-based medicine and patient-choice individual rights (eg, patient autonomy) and responsibilities  Summary memory, understanding Patien beliefs (lay, re illness and t treatment), satisfaction barriers to adherence, Dr/patient communication interaction concordance ADHERENCE ? support, housing, Social & employment etc. psych care setting context psych problems side-effects, complexity Treatment experience, efficacy, stigma