Why patients do not adhere to medical advice.

1. Why patients do not adhere to medical advice. Health Psychology

2. Compliance • Adherence • Concordance • Degree to which the patient carries out the behaviours the physician recommends (e.g., taking medication).

3. Extent of non-adherence problem • Difficulties with assessing it: • Many different kinds of medical advice to which one could adhere • Can violate advice in many different ways • Difficult to know if patient complied (50/50 chance that the physician’s judgment of the patient’s adherence is accurate).

4. Adherence • 60% of patients may not be adhering to long-term treatment regimen 1-2 years later • even in cardiac patients medication adherence over time is poor (i.e., 40% nonadherent 3 years later) • Good predictor of long-term adherence is adherence at entry • Distribution of adherence is tri-modal

5. 1/3 Distribution of Adherence 1/3 1/3

6. Measuring Adherence in Clinical Practice • Physician impression overestimates patient-adherence by about 50% (Caron, 1985). • Electronic monitors of pills taken are impractical in routine clinical practice. • Bio-chemical measures also have limitations • Self-report methods are good at detecting those who admit to adherence difficulties but will miss-classify about 50% patients who deny problems or who areunaware of a problem.

7. Forms of Non-Adherence • Forgetting a dose • Deliberately skipped doses • Occasional day or even week off therapy • Stopped therapy

8. Patients’ Reasons for Not Adhering • Forgetfulness (e.g., restaurant, trip) • Financial (wait until pay day, take 1/2 dose to delay renewing prescription) • Feeling sick • Feel well (rare reason) • Lazy about going to the drug store • Too busy - forget • Life events, stress (e.g., death in family) • Don’t believe in the treatment • Confused about dosage

9. Rational Reasons for Non-adherence • Have reason to believe the treatment isn’t working • Feel that side-effects are not worth the benefits of treatment • Don’t have enough money to pay for treatment • Want to see if the illness is still there when they stop the treatment

10. Non-adherence: Characteristics of the regimen • Complex regimens have low adherence • Adherence decreases with duration of the regimen • Expense decreases adherence

11. Non-adherence: Cognitive-Emotional Factors • Patients forget much of what the doctor tells them • Instruction and advice are forgotten more readily than other kinds of information • The more patient is told, the higher the likelihood of forgetting more. • Patients remember what they are told first and what they think is most important.

12. Non-adherence: Cognitive-Emotional Factors • More intelligent patients do not remember more than less intelligent patients • Older patients remember as much as younger patients • Moderately anxious recall more than low or high anxious patients • The more medical knowledge the patient has, the more he/she will remember.

13. Non-Adherence: Psychosocial Factors • Social support • Personality - Dispositional Attitudes • Affective State • Knowledge and attitudes

14. Non-Adherence: Knowledge/Beliefs • Lack of knowledge • Denial or trivialization • Perceived invulnerability Necessary but not sufficient

15. Non- Adherence - Behaviour • Early adherence, e.g., within first month of initiating therapy is an excellent predictor of later adherence, even 7 years later (Dunbar & Knoke, 1986) • The more similar the predictor behaviour to the predicted behaviour, the higher the correlation. • Generally, little evidence for a health-oriented behaviour pattern.

16. Whey don’t people adhere? • Did not understand the treatment regime (inadequate or non-existent instructions) • Forget • Side effects • Lack of commitment • Travel away from home • Depression • Feel better – did not see need for completion

17. Why do people fail to take medicines properly? • Non-adherence leads to • ineffective treatment • Additional health care expenditure • Anti-biotic resistance

18. How can services can help adherence? • Spend time explaining the importance of adherence and help them to choose strategies thatcan help them to adhere • More appropriate drug regimes (e.g. shorter times for completion of treatment) • More acceptable presentation e.g. sugar coated anti-malarials, syrups etc. • Suitable packaging – blister packaging – lay-out • Instructions with the packaging - simple words/pictures • Involve partners so they can remind their partners

19. Medicine labelling/packaging Used to explain Dose, timing, side effects, things to avoid while taking medicines Communication depends on: Size/clarity of letters Language and complexity of words Literacy of audience and familiarity with medical terms Quality/comprehensibility of pictures and picture symbols e.g. sun/moon for time of day

20. Increasing Patient Adherence • Use clear (jargon free) sentences • Repeat key information • Recruit sources of support • Tailoring the regimen • Providing prompts and reminders • Self-monitoring • Behavioural contracting

21. Strategies that people can use to remember doses • Integrate regimes into daily routines • Have a checklist for recording doses taken • Count out daily doses as week at a time • Use a pill box, alarm or daily planner

22. Examples of methods methods used to encourage adherance • Leaflets, instructions • Blister packaging • A programme in South Africa used text messaging to remind people to take their tuberculosis medicines • Visual aids like calendars • Poster warning dangers of combining drugs and alcohol (Nicaragua)

23. Poster put up on the walls of clinics in UK to prevent unnecessary use of antibiotics

24. Extent of problem • Taylor (1990) 93% of patients fail to adhere to some aspect of their treatment.

25. Extent of problem • Sarafino(1994) People adhere to treatment regimes reasonably closely 78% of the time. • Sarafino found the average adherence rates for taking medicine to prevent illness is 60% for short and long term regimes. • Compliance to change one's diet or to give up smoking is variable and low.

26. Extent of problem • Compliance with chemotherapy is very high among adults with estimates of better than 90 percent of patients complying with the treatment.

27. Extent of problem • Non compliance takes many forms. Some patients do not keep appointments; others do not follow advice. • Many patients fail to collect their prescriptions, discontinue medication early, fail to change their daily routine, and miss follow-up appointments (Sackett and Hayes, 1976).

28. Kent and Dalgleish (1996) • Kent and Dalgleish (1996) describe a study in which many parents of children who were prescribed a ten-day course of penicillin for a streptococcal infection did not ensure that their children completed the treatment. • The majority of the parents understood the diagnosis, were familiar with the medicine and knew how to obtain it.

29. Kent and Dalgleish (1996) • Despite the fact that the medication was free, the doctors were aware of the study and the families knew they would be followed up, by day three of the treatment 41% of the children were still being given the penicillin, and by day six only 29% were being given it.

30. (Ley, 1997). • The costs associated with non-adherence can be high. • The illness may be prolonged in the patient and he or she may need extra visits to the doctor. • These are not the only costs, however, as the person may have a longer recovery period, might need more time off work or even require a stay in hospital.

31. (Ley, 1997). • Non-adherence may lead to as much as 10%—20% of patients needing a second prescription, 5%—10% visiting their doctor for a second time, the same number needing extra days off work, and about 0.25 %—1% needing hospitalisation (Ley, 1997).

32. Methodological problem • Percentages are overestimated because patients who tend to volunteer for these studies would be more likely to be compliant.

33. Methodological problem • Patients often lie about their level of adherence, so as to present a good impression of themselves. • It has been reported in the press that those patients who smoke may be afforded a low level of priority, when they are in need of a transplant. • Patients might lie about their smoking, to avoid such discrimination.

34. Why patients do and don't adhere to advice • Patients are less likely to change habits than heed medical advice to take medicine (Haynes, 1976).

35. Why patients do and don't adhere to advice • Patients who view their illness as severe are more likely to comply (Becker & Rosenstock, 1984). • Notice it is how the patient views the seriousness of the illness, not what the physician thinks!

36. Why patients do and don't adhere to advice • Doctors tend to blame their patients for non-adherence, attributing their behaviour to characteristics of their patients (mental capacity or personality traits) - Davis (1966).

37. Why patients do and don't adhere to advice • Research has shown that it is not the patient's personality that predicts non-adherence, but a combination of factors arising out of the doctor - patient relationship (e.g. Ley 1982). • Factors such as age and gender are predictive of compliance, depending upon what instructions are to be complied with.

38. Classic experiments - Milgram (1963) and Asch (1955. • Milgram's experiment demonstrated that ordinary people will obey authority figures, to the extent that they would administer potentially lethal 'electric shocks' to a mild-mannered victim. • Asch's experiment demonstrated that people will agree with others even though it is obvious others are wrong.

39. (Haynes 1976). • If medication is prescribed over a long time, it's more likely to be discontinued early (Haynes 1976).

41. Types of request • requests for short-term compliance with simple treatments • requests for positive additions to lifestyle • requests to stop certain behaviours • requests for long-term treatment regimes

42. Ley model of patient compliance (1989).

43. Patient satisfaction • Ley (1988) reviews 21 studies of hospital patients and found that 28% of general practice patients in the UK were dissatisfied with the treatment they received. • Dissatisfaction amongst hospital patients was even higher with 41 per cent dissatisfied with their treatment.

44. Patient satisfaction • The dissatisfaction stemmed from affective aspects of the consultation (e.g. lack of emotional support and understanding), behavioural aspects (e.g. prescribing, adequate explanations) and competence (e.g. appropriateness of the referral, diagnosis).

45. Patient satisfaction • It was found that patients were "information seekers" (i.e. wanted to know as much information is possible about their condition), rather than "information blunters" (i.e. did not want to know the true seriousness of their condition).

46. Patient satisfaction • Over 85% of cancer patients wanted all information about diagnosis, treatment and prognosis (the chances of treatment being successful) (Reynolds et al., 1981).

47. Patient satisfaction • 60 to 98% of terminally ill patients wanted to know their bad news (Veatch, 1978).

48. Patient satisfaction • Older research had found that a small but significant group did not want to be given the truth for cancer and heart disease (Kubler-Ross, 1969). • These findings could be due, in part, to the attitudes that prevailed during the late Sixties. • Research suggests that attitudes have changed since then.

49. TESTING A THEORY - PATIENT SATISFACTIONA study to examine the effects of a general practitioner's consulting style on patient satisfaction (Savage and Armstrong 1990).

50. Methodology • Subjects • The study was undertaken in group practices in an inner city area of London. • Four patients from each surgery for one doctor, over four months were randomly selected for the study.