adherence

• Non-adherence


  When an individual does not follow treatment plans, or does not attend appointments based on their advice from physicians. This leads to morbidity and mortality.
• Non-adherence


  • Not attending your follow up consultation session
  • If an individual was told to take their medication every day for 2 weeks and they stop it after 3 days
• Types of non-adherence


  • Failure to follow treatment
  • Failure to attend appointments
• Unintentional non-adherence


  The patient wants to follow a treatment but there are uncontrollable barriers: not remembering, not understanding the doctor, unable to afford treatment, unable to take time off work, simply forgot
• Intentional non-adherence


  The patient decides not to follow treatment. This may be due to their beliefs, levels of motivation or lack of faith in the treatment
• Intentional factors for non-adherence (Laba et al. 2012)


  • Immediate medication harms
  • Long-term medication harms
  • Immediate medication benefits
  • Long-term medication benefits
  • Financial cost of medication
  • Regime
• Predictors of failure to attend appointments

  • Age (either young or over 80 years old)
  • Work commitments difficulties getting to hospital
  • Feeling an appointment is unnecessary
  • Being too ill to attend
  • Fear/mistrust of hospitals
  • Fear of serious illness being discovered
• Groups most likely to miss appointments

  • Those under 21
  • Those from low social status/class
  • Individuals who have missed appointments previously
  • Those who already have a mental or physical diagnosis
  • Minority ethnic groups
• Problems caused by non-adherence

  • Unresolved medical problems
  • Cost to health service
  • Delayed treatment, leading to later need for more expensive, stronger medication or later need for surgery
• Rational non-adherence


  Weighs the cost and benefits of adhering, if the costs outweigh the benefits then there will non adherence, if the benefits outweigh the costs then people would adhere. It relies on a cognitive thought process and evaluation of the individual.
• Rational non-adherence


  • If someone has to adhere to hypertension medication, they would weigh the cost of adhering which would include side effects like: sexual impotence, tiredness, fatigue, nausea and the benefits which would include a stroke prevention. Then they would choose based on that, their likelihood to adhere.
• Reasons for rational non-adherence


  • Believing medication is not helping
  • Feeling that the side effects outweigh the benefits
  • Being confused about how often/how to take medication
  • Not having enough money to buy medication
  • Wanting to see if they still have the illness if they stop taking medication
• Health Belief Model


  Proposes that the individual would have to assess their perceptions before following treatment plan understanding this assessment can lead to levels of adherence. Includes evaluating susceptibility, seriousness, perceived benefits and barriers, modifying factors, and cues to action.
• Taking preventative action when faced with potential illness or injury depends on how much of a threat the health problem poses and the pros and cons of taking action
• Other factors in the Health Belief Model include demographic variables, personality traits and social class
• Laba et al. (2012) study


  • Aimed to explore decisions that may lead to intentional non-adherence behaviour and the relative importance of medication-specific factors and patient background
  • 248 Australians participated, median age 57, 45% male, 55% female
  • Six out of eight factors influenced medication choice
  • Those with medical insurance were less sensitive to costs
  • Side effects had greater influence than benefits to health
  • Ability of medication to reduce death was most important, followed by current side effect severity and future side effect risk
• Laba et al. concluded that patients make rational choices, and adherence could be improved by reducing costs of medication, altering regime, and educating patients on medication benefits
• Evaluating Laba et al.


  • High in applicability - results show factors influencing adherence, so practitioners can design interventions
  • Low in generalizability - only 161 out of 1,668 invited participants completed the questionnaire
  • High in reliability - used standardized BMQ measure
  • Low in ecological validity - used hypothetical questions not real-life situations
  • Low in validity - relied on self-reports which may be inaccurate
• Subjective methods of measuring non-adherence

  Clinical Interviews & Questionnaires including MARS
• Objective methods of measuring non-adherence

  Urine and blood samples, Pill counting, Chung and Naya
• Riekert and Drotar (1999) study


  • Aimed to assess implications of non/incomplete participation of adolescents with diabetes in treatment adherence research
  • 52 out of 94 families completed the study
  • Adolescents of non-returner families tested their blood glucose levels significantly less frequently and had lower adherence rates than those who returned questionnaires
  • Concluded that lower adolescent adherence is associated with lower participation in adherence studies
• Evaluating Riekert and Drotar

  • High in applicability - showed families failing to complete research may lack organizational skills
  • Low in ethics - used data from non-consenters without approval
  • High in validity - used objective measures like blood glucose monitoring
  • Low in validity - self-report measures lack precision in assessing adherence
• research tasks may lack organizational skills. This allows real-life interventions for practitioners to give their patients organizational tips.
• Low in ethics – Riekart and Drotar used data from non-consenters. Therefore, they broke the ethical guideline of informed consent as they used information without participants' approval.
• High in validity – The number of blood glucose tests was monitored through a reflectance meter, metabolic control was measured at clinic appointments, and parents completed a questionnaire on demographics and the family took two questionnaires, to be mailed back. Hence, the use of objective methods to gather quantitative data eliminates researcher bias and increases validity.
• Low in validity – self-report measures rarely provide time-stamped data for adherence behavior, which limits precision when assessing timing or patterns of dose-taking.
• Objective measures
• Relevant research: Chung and Naya (2000)

  Aim: to electronically assess compliance with an oral asthma medication.
• Methodology


  1. Forty-seven patients with asthma, aged 18-55

  2. Two to three weeks of screening, then 12 weeks' treatment; one pill twice a day

  3. Tablets in bottles fitted with TrackCap recording date and time when opened

  4. Patients gave informed consent but did not know about the device

  5. Tablet count and TrackCap removal were both measured
• Results: There was 80 per cent compliance with TrackCap (taken off twice a day); 89 percent compliance with tablet count. Difference due to patients taking out more than one tablet at a time, maybe to put in a dispenser. There was 64 per cent compliance on TrackCap and tablet count: two tablets daily, 12 hours apart. Under-compliance by 20 per cent of participants: one tablet removed daily. No compliance for up to eight days by 10 per cent of participants.
• Conclusion: monitoring systems like TrackCap measure adherence effectively.
• Biological measures of adherence

  • These provide assurance that medication has been taken, not just removed from the bottle
  • They allow for a personally adjusted dose to be calculated

  
• Chung and Naya


  • High in ecological validity – Chung and Naya measured adherence at the patients' homes where they would normally be taking the medication. Hence, the study can be considered high in ecological validity.
  • High in reliability – The use of a Track cap makes the procedure highly standardized and easy to replicate.
  • Low in validity – The Track cap cannot determine whether the patient ingested the tablet or not. Therefore, we cannot know if the patient is actually adhering to medical advice or not. This lowers the validity of the findings.
  • Limited in usefulness - biochemical tests do not measure the degree of adherence; the presence of a drug merely shows that the patient has taken an amount of the drug. It does not indicate that the patient took the proper amount at the proper time.
• Qualitative and quantitative methods have strengths and weaknesses. Reikert and Drotar (1999) used method triangulation to gain quantitative and qualitative data, improving the validity of results. Chung and Naya (2000) used objective quantitative measures, which told them about adherence, but not the reasons for this.
• Research into reasons for non-adherence can be applied to improve the medical profession's understanding of why people may not adhere to advice or regimes, and what they can do about it.
• Strategies to improve adherence in children

  • simple regime
  • pleasant-tasting medicine
  • easy-to-take liquids rather than tablets
  • text message reminders for older children
  • regular phone contact with parents
  • involving children fully with treatment plans, considering their concerns (Benn, 2014)
• Relevant research: Chaney et al. (2004)


  Aim: to compare the Funhaler device to currently used spacer devices.
• Methodology


  1. Participants were 32 children aged 1.5-6 years old diagnosed with asthma, currently using a standard spacer device

  2. They were randomly recruited through seven local clinics

  3. Parents were initially telephoned before any home visits were conducted

  4. Informed consent was given and parents were interviewed by questionnaire about their child's current asthma device

  5. The questionnaire included questions about problems associated with the delivery of the medication and parental and child adherence to using the device

  6. The Funhaler device was used instead of the current device for two weeks (with adult supervision)

  7. Parents were contacted once by phone randomly to see if they had medicated their child the previous day

  8. The families were visited at home at the end of the two-week trial

  9. A second questionnaire regarding use of the Funhaler was completed by the same parent
• Results: The Funhaler could be useful in managing asthma in young children. It could improve clinical outcomes in children. Behaviourist theories (like operant conditioning) are effective in increasing children's adherence to medication.
• Chaney et al.


  • High in ethics - Informed consent obtained from parents, who were briefed on the aims of the study and all data responses were anonymised, which ensured their privacy
  • High in reliability - Procedure and materials were standardised and all participants were given same instructions so findings are reliable and the study can be replicated.
  • Low in validity - the study's findings rely on self-report, which is open to bias as participants might over-report use of the Funhaler due to social desirability
  • Ethnocentrism - Behaviourists believe external factors [including complex cultural differences] can play a part in reinforcing desirable behaviours. Although Funhaler's features used to influence children regardless of location, could be other social and cultural influences that affected compliance rate in this study.