L12: Patient Attitude to Medicine

• Attitudes


  A settled way of thinking or feeling about something
• Behaviour


  The way in which a person behaves in response to a particular situation or stimulus
• Behaviours is often informed by attitude
• Importance to pharmacist as a health care professional

  • Understanding behaviour in health consultation assists understanding medication taking behaviour
  • Pharmacists need to understand patient behaviour in consultation to help patients optimise medicine usage and deliver person-centred care
  • Optimisation important for achieving clinical and cost related outcomes
• Compliance


  The extent to which the patient's behaviour matches the prescriber's recommendations. However, its use is declining as it implies lack of patient involvement.
• Adherence


  The extent to which the patient's behaviour matches agreed recommendations from the prescriber
• Concordance


  Focused on the consultation process, in which doctor and patient agree therapeutic decisions that incorporate their respective views, to a wider concept which stretches from prescribing communication to patient support in medicine taking
• 33- 50% patients on long term treatment do not take medicines 'correctly' as prescribed
• Understanding the patient's perspective - NICE guidance

  • Patients sometimes make decisions about medicines based on their understanding of their condition and possible treatments, their view of their need for the medicine and their concerns
  • Ask patients what they know and believe about medicines and their need for a medicine before prescribing and when reviewing
  • Addressing their concerns e.g. what will happen if they don't take the medicine, non-pharmacological alternatives, reducing or stopping long-term medicines, fitting medicines into their routine, choosing between medicines
• National figure of medicines waste is estimated to be £300 million. This sum represents approximately £1 in every £25 spent on primary care and community pharmaceutical and allied products use, and 0.3 per cent of total NHS outlays. It includes an estimated £90 million worth of unused prescription medicines that are retained in individuals' homes at any one time, £110 million returned to community pharmacies over the course of a year, and £50 million worth of NHS supplied medicines that are disposed of unused by care homes.
• Person-centred care


  Focusing care on the needs of individual. Ensuring that people's preferences, needs and values guide clinical decisions, and providing care/treatment that is respectful of and responsive to them.
• Non-adherence: Intentional and non-intentional

  • Intentional: Related to attitudes, beliefs and concerns or problems about the medicines
  • Non-intentional: practical problems
• Any type of non-adherence should not be seen as the patient's problem. It represents a fundamental limitation in the delivery of healthcare, often because of a failure to fully agree the prescription in the first place or to identify and provide the support that patients need later on.
• The disease is not serious now, I am not sure whether need medicines and should I continue medicines or not? (68 years, male of Indian origin participant no. 1): 'Participant's quote on non-adherence'
• I was healthy and I didn't take medicine all my life and then suddenly you have 6 different medicines a day this is a confusion: 'Participant's quote on non-adherence'
• 'No I didn't go to cardiac rehabilitation. If they start putting injections again, I do not want to go through that again': 'Participant's quote on non-adherence'
• Patients' Fears


  • Addiction
  • Psychological dependence
  • Concerns about tolerance
  • 'Drug holidays'
  • Fear of masking symptoms of disease
  • Manufactured medicines are unnatural
• Other factors influencing decisions to take medicines

  • Cost – ability to pay
  • Repeat prescribing arrangements
  • Interruptions to daily routine
  • Being away from home
  • Forgetfulness
  • Stress
• Measuring adherence and non-adherence

  • Consider assessing non-adherence by asking the patient if they have missed any doses of medicine recently. Make it easier for them to report non-adherence by: asking the question in a way that does not apportion blame, explaining why you are asking the question, mentioning a specific time period such as 'in the past week', asking about medicine-taking behaviours such as reducing the dose, stopping and starting medicines.
  • Consider using records of prescription re-ordering, pharmacy patient medication records and return of unused medicines to identify potential non-adherence and patients needing additional support.
• Measures of adherence/non-adherence


  • Direct measures e.g. blood tests
  • Pill count
  • Measures involving clinician assessments and self-report
• Hill-Bone Scale for measuring adherence to high blood pressure medicines

  14 items of which 9 items measuring adherence. Scores (1-4 for each item) giving a maximum of 36 points. Score 9 is perfect adherence and 36 is total non-adherence.
• Promoting adherence


  • Addressing non-adherence is not about getting patients to take more medicines per se. Rather, it starts with an exploration of patients' perspectives of medicines and the reasons why they may not want or are unable to use them.
  • Requires a frank and open approach which recognises that non-adherence may be the norm (or is at least very common) and takes a no-blame approach, encouraging patients to discuss non-adherence and any doubts or concerns they have about treatment
  • A patient-centred approach that encourages informed adherence
  • Identification of specific perceptual and practical barriers to adherence for each individual, both at the time of prescribing and during regular review, because perceptions, practical problems and adherence may change over time.
• Key principles for promoting adherence

  • Adapt consultation style
  • Make patients involved
  • Patient has right not to take their medicine
  • Be aware that patients' concerns about medicines- e.g becoming dependent on medicines, and concerns about adverse effects. Address these concerns.
  • Provide information- do not assume patient information leaflet will provide the information
  • Tailor any intervention to increase adherence to the specific difficulties with adherence the patient is experiencing
• Healthcare professionals are reminded of their duty under the Disability Discrimination Act (2005) to make reasonable adjustments to ensure that all people have the same opportunity for health.
• Kleinman's Model


  Eliciting the patient's (explanatory) model gives the healthcare professionals (HCPs), the knowledge of the beliefs the patients holds about their illness, the personal and social meaning they attach to their disorder, their expectations about what will happen to them and what the HCP will do, and their own therapeutic goals
• Questions in Kleinman's Model

  • What do you think has caused your problem?
  • Why do you think it started when it did?
  • What do you think your sickness does to you?
  • How does it work?
  • How severe is your sickness?
  • Will it have a short or long course?
  • What kind of treatment do you think you should receive?
  • What are the most important results you hope to receive from this treatment?
  • What are the chief problems your sickness has caused for you?
  • What do you fear most about your sickness?
• Promoting adherence- examples


  • Review medications, effectiveness, side effects
  • Suggesting that patients record their medicine-taking
  • Encouraging patients to monitor their condition
  • Simplifying the dosing regimen
  • Using alternative packaging for the medicine
  • Using a multi-compartment medicines system
  • Communications across healthcare professionals
  • Apps/reminders
• Communicating Risk - understanding

  Cate's plot (Smiley faces), BNF definition of 'rare', 'common', Accident diagram
• Directly Observed Therapy (DOT)


  • A specific strategy, endorsed by the World Health Organization, to improve adherence to anti-tuberculosis medicines by requiring health workers, community volunteers or family members to observe and record patients taking each dose.
• COM-B model of behaviour

  • An individual must have adequate capability, opportunity, and motivation for a behaviour (e.g. adherence to medicine-taking) to take place
  • Capability: influenced by physical factors such as dexterity or eyesight, and psychological factors such as knowledge and memory
  • Opportunity: Influenced by factors such as environmental constraints, such as difficulties getting to pharmacies; social factors such as stigma for HIV patients' medication taking behaviours
  • Motivation: Self-confidence and beliefs
• Theoretical domains framework (TDF)


  A theoretical framework of determinants of behaviour. It combines 33 theories and consists of 14 domains (or potential factors that determines a behaviour): Knowledge, Skills, Social/Professional Role and Identity, Beliefs about Capabilities, Optimism, Beliefs about Consequences, Reinforcement, Intentions, Goals, Memory, Attention and Decision Processes, Environmental Context and Resources, Social Influences, Emotions, and Behavioural Regulation
• Barriers of adherence to medicines amongst homeless patients (Use of TDF to understand behaviours)

  • Environmental context and resources: 'When you are homeless, you are not thinking about your medication; but your food, shelter or heat for the night.'
  • 'You are keeping (medicines) in your socks, down your trousers. Because if you fall asleep and its in your socks it could be quite easily stolen.'
  • 'Never had money for bus fares and sometimes I wasn't actually fit to walk up to my chemist. Sometimes people would (offer) lift and they wouldn't turn up.'
• Homelessness affected patient adherence to medicines in all stages of patients medicines journey
• Paying people with psychosis to improve adherence

  • >50% people with schizophrenia estimated not to adhere to prescribed drugs
  • Many patients do not accept that they are ill, therefore do not see that they need treatment
  • Serious side effects are associated with some treatments, diabetes, obesity and neurological side effects
• 'Even the most effective interventions did not lead to large improvements in adherence or clinical outcome'
• Summary


  • Patient attitudes to medicines and behaviours are closely interlinked
  • Theoretical models help us understand patient attitudes and behaviours towards medicines and identifying best interventions in clinical practice
  • Interventions should be person centred, 'one size fits all' approach does not work