Adherence to Medical Regimen

Healthy Living: explaining health behaviours

FEATURES OF ADHERENCE TO MEDICAL REGIMES

·         REASONS FOR NON-ADHERENCE: Bulpitt et al. (1988)/Lowe and Raynor (2000)

·         MEASURES OF NON-ADHERENCE: Lustman (2000)/Becker (1978))

·         IMPROVING ADHERENCE USING BEHAVIOURAL MEASURES: Watt et al. (2003)

REASONS FOR NON-ADHERENCE

Adherence to medicines is defined as the extent to which the patients’ action matches the agreed recommendations. Non-adherence can include changing the frequency or dosage of medicines, as well as neglecting to follow agreed actions such as exercise or stopping smoking. Whilst non-adherence can result in deterioration of health and wasted medication, there are various reasons why people don’t adhere to advice they’re given in terms of health. Reasons for non-adherence tend to come under two categories: intentional non-adherence and unintentional non-adherence. Unintentional non-adherence features reasons such as forgetfulness, inability to pay, and confusion, which meant that despite wanting to adhere, they were unable to. Intentional non-adherence occurs when there is a conscious decision not to follow advice, and is best understood in terms of perceptual factors such as believing that the medicine won’t work or is against their ethics (such as a vegan who will not eat meat to improve health), or practical factors, such as the side-effects the medicine produces.

EVALUATION: REASONS FOR NON-ADHERENCE

There are some issues with trying to decipher somebody’s reasons for non-adherence. The most appropriate research method into this is self-report; however social desirability bias, demand characteristics and dishonesty may distort the findings. Non-adherence may also be for a combination of factors, or unique to an individual or group, so finding ways to overcome non-adherence could be quite difficult; however, if it is achieved, the health and money benefits could be beneficial to a lot of people. Another weakness of looking at non-adherence is the validity of the research and theories, as it is difficult to operationalize non-adherence – if somebody takes roughly the right amount of pills, is that adherence? What about if they take them at slightly the wrong time of day? As researchers operationalize adherence differently, research may lack reliability as it cannot be compared and checked with other research. We must be careful when attempting to generalize adherence behaviour, as different illnesses may bring out different attitudes and behaviours in people.

STUDY: BULPITT et al. (1988)

Bulpitt et al. conducted a review article study on non-adherence to taking medication to regulate high blood pressure (hypertension). Various pieces of research were looked at to identify problems with taking drugs for high blood pressure. Both physical and psychological side effects were looked at, including problems at work and the effects on physical wellbeing. The study found that anti-hypertension medication had many side effects including sleepiness, dizziness, impotence, and weakened cognitive functioning. Curb et al.’s study that 8% of males discontinued treatment due to sexual problems, whilst the medical research council found that 15% withdrew due to side effects. It was concluded that when side effects outweighed the benefits of treating a mainly asymptomatic problem such as hypertension, there is less likelihood of the patients adhering to their treatment.

EVALUATION: BULPITT et al. (1988)

The problem with using the methodology of a review article is that it looks at dated research, which may lack temporal validity. On the other hand, this enables the researcher to look at patterns and see if attitudes towards medication and adherence change over time, which may be more useful. The use of various pieces of research allows for cross-referencing and increased reliability and generalizability of the findings. As both physical and psychological side effects were investigated, this study appears to be more holistic in its approach. It is not known, however, the depth or validity of the research that was looked at, and the review article appears to be fairly brief.

STUDY: LOWE AND RAYNOR (2000)

Another study into reasons for non-adherence is Lowe and Raynor (2000). The research was conducted on a random sample of 161 patients aged 65 years and older. The mean age of the sample was 76 years, and the mean number of medicines prescribed was 4. The cognitive study used a self-report method, whereby participants were visited and interviewed at home using a structured questionnaire. They were asked questions on which medicines they took, the dosage they take and the frequency dosages are taken. The results showed a discrepancy in 53% of cases. In 28 out of 86 cases, this was due to administrative error, 3 cases were due to confusion and the remaining cases were due to a rational decision by the patient.  92 medicines in all were involved, of which 51 were no longer being taken, 19 dosages had been adjusted and 22 frequencies were adjusted. The reasons given by the sample included side-effects, believing the drugs did not work, and adjustment to fit daily routine. The conclusion was that contrary to popular belief, very few of the elderly who do not adhere to medical regimen are actually confused about it: most make a rational decision by weighing up the costs and benefits, and their non-adherence tends to mostly be intentional. It was deemed “concerning” that patients did not communicate their decisions with their doctor, and that so many administrative errors had been made by the doctors.

EVALUATION: LOWE AND RAYNOR (2000)

The sample was fairly limited in that it looked at a vulnerable, age-biased group (the elderly), however as it was random it is likely that the sample is representative of elderly people. The use of a vulnerable sample however raises ethical issues as they may have felt pressured into giving consent, or not felt that they could have withdrawn from the study. The use of a self-report method is effective in that it enabled participants to recall what they had done and give attitudes, however self-report brings issues of internal validity due to dishonesty, demand characteristics and social desirability bias. As the report was asking for certain amounts of retrospective data, forgetfulness may also have been an issue. The use of a structured questionnaire boosts the reliability of the study, as does comparing the results from the study with medical records. This is a very useful study as it provides reasons for intentional non-adherence, and shows that the common belief about the elderly being confused about medication is somewhat fabricated. It also demonstrated the need for doctors’ surgeries to check for administrative errors, and that communication is lapse between doctors and patients in terms of non-adherence.

MEASURES OF NON-ADHERENCE

There are various ways in which it has been proposed that adherence can be measured: using self-report, looking at the therapeutic outcome (did the patient get better?), asking the doctor, counting pills and bottles, mechanical methods (such as the track cap) and biochemical tests (such as blood and urine tests). As none of these methods are without their faults, methodological triangulation appears to be the most appropriate and accurate way of measuring (non-)adherence.

EVALUATION: MEASURES OF NON-ADHERENCE

Each method of measuring adherence has strengths and weaknesses. Using self-report allows attitudes to be given and is most convenient, but may lack internal validity. Asking the doctor means that social desirability bias wouldn’t be an issue, however patients may have lied to their doctors about their level of adherence. Counting pills and bottles may appear to show what has been taken, but someone may have removed pills and not taken them, or taken more than their recommended dosage one day then nothing the next. It is also an invasion of privacy to check this. Mechanical methods are expensive but can be useful in conjunction with self-report or biochemical tests, and biochemical tests mean that dishonesty isn’t an issue, but they are expensive, time consuming and only show adherence at one point in time, so may be misleading. 

STUDY: LUSTMAN (2000)

Lustman’s study looked into using physiological measures of assessing adherence to medication and the treatment of depression in diabetics. The aim of the study was to assess the effectiveness of fluoxetine as treatment for depression in diabetics. A self-selected sample of 60 diabetic volunteers with depression was involved in a laboratory experiment, using a double blind technique. All were screened for depression and randomly assigned to two groups (the group who would take the drug, and one who would take the placebo). Participants were given daily doses of the medication for 8 weeks, and then re-assessed for depression and their adherence to their medical regimen through measuring blood sugar levels. The results showed that reduction of depression was significantly greater in the experimental group than the control group, and that these patients also had nearer normal blood sugar levels, which indicated improved adherence. The conclusion from this research is that physiological tests were an effective method of measuring adherence, and that reduced depression may improve adherence in diabetic patients. 

EVALUATION: LUSTMAN (2000)

Whilst the use of a laboratory experiment, double blind design and control group should improve the internal validity of the study due to removal of certain confounding variables (such as self-fulfilling prophecy), the use of an independent measures design (which introduces participant variables) balances this out. The participants may simply have gotten better at adherence and felt better within themselves; it may have had very little to do with the drug, however the control group did show that it was not the placebo or Hawthorne effect. The study is useful as it provides another reason for non-adherence, a way of measuring non-adherence, and suggests a way to improve adherence. The extent to which the results can be generalized is limited due to the small, biased sample.

IMPROVING ADHERENCE USING BEHAVIOURAL MEASURES

Sometimes, non-adherence to medical regimen is not particularly serious, as sometimes symptoms and illnesses clear up by themselves. However, non-adherence can prove fatal, and it is these cases which require health psychology to combat non-adherence. Potentially the most useful psychological standpoint in terms of a perspective or approach to non-adherence is the behavioural perspective, as it is a practical and nomothetic viewpoint. Some appropriate behaviourist techniques in combatting non-adherence include direct reinforcements (positive reinforcement), modelling (imitation – this could be from a support group, for example), and contingency contracts (whereby the patient negotiates with the health worker concerning goals and rewards for achievements).

EVALUATION: IMPROVING ADHERENCE USING BEHAVIOURAL MEASURES

The main issue with attempts to improve adherence is that the method used depends on the approach that the problem is explained in terms of, and this will often mean methods are reductionist – this makes them simple to understand and easy to apply to different contexts, but is also likely to be overly simplistic in an area of behaviour which is fairly complex. Combined methods are therefore most likely to be effective. Cultural differences also complicate things; different cultures view medicine and illness differently, so it is likely that findings and theories from one culture cannot be generalized to different cultures. Individual differences should also be a consideration: people differ individually to what they will adhere to and their reasons behind it based on their individual differences. For example, women have been shown to visit doctors more quickly after becoming ill than men. The focus of improving behavioural measures on behaviourism is reductionist in that behaviourism ignores freewill, context and individual differences such as religion.

STUDY: WATT et al. (2003)

Previous research had suggested that non-adherence in children with asthma could be due to boredom, apathy and forgetfulness. This study aimed to see if using a Funhaler instead of a regular inhaler could improve children’s adherence to taking asthma medication. 32 asthmatic children with a mean age of 3.2 years, who had been prescribed drugs taken via an inhaler, were involved in the study. Parental consent was gained, as the children were too young to give informed consent. The method was a field experiment using a repeated measures design, assessed through self-report. The independent variable was whether the child used the inhaler or Funhaler, and the dependent variable was the level of adherence to taking their asthma medication. For the first week, children used regular inhalers, and in the second week the Funhaler was used – a device which incorporates features to distract the child from the drug delivery and reinforces the use of the Funhaler, such as a spinner and a whistle which work best when the deep breathing required for effective drug delivery is used. After each week, the parents completed a questionnaire on adherence. The results were that 38% more parents reported higher adherence in the children when using the Funhaler, and thus it was concluded that making a medical regimen fun can improve adherence in children.

EVALUATION: WATT et al. (2003)

The main issue with this study in terms of methodology is that it was conducted over a fairly short time span. Whilst adherence may have improved with the use of the Funhaler, this may have been due to novelty which could have worn off fairly quickly after the initial week’s use, as behaviourist research has found that constant reinforcement is less rewarding that partial reinforcement. This study is useful because it tested uptake of the medication through both self-report from the parents and through calculating the volume of air in the Funhaler, and thus the amount of medication absorbed by the child. The Funhaler is widely available to asthmatic children, and may well be a lifesaver as it can help to control asthma. However, making medication regimen fun may only work for very young children, and for medication taking through an inhaler rather than orally or through injection, so the findings are unlikely to be able to be generalised, reducing how useful it is.

General points on evaluation of adherence: adherence can be affected by a wide range of patient beliefs, so a holistic approach is desirable. Ethics are potentially an issue due to the samples, and in Becker, the lack of parental consent. Physiological measures of adherence are most reliable, whilst self-report studies have questionable validity.