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. 

Past paper questions (June 2012)

Happy Thursday guys! Hope your revision is going well; here's some past paper questions from last year's paper to keep you going. I'll be doing these over the next day and a half, so if you've got a query, leave a comment!

Forensic Psychology

1. TURNING TO CRIME       
(a) Describe how social cognition can explain criminal behaviour (10) (b) Evaluate the validity of research into cognitive explanations of criminal behaviour (15)

2. MAKING A CASE
(a) Describe how top-down typology is used to create a profile (10) (b) Assess the usefulness of qualitative and quantitative data when creating a profile (15)

4.  AFTER A GUILTY VERDICT      
(a) How can probation serve as an alternative to imprisonment? (10)(b) Evaluate limitations of research into alternatives to imprisonment (15)


Health and Clinical Psychology6.  STRESS 
(a) Describe self-report as a method of measuring stress (10) (b) Compare different measures of stress (15)

7.   DYSFUNCTIONAL BEHAVIOUR    
(a) How has dysfunctional behaviour been defined? (10) (b) To what extent may diagnoses of dysfunctional behaviour be considered ethnocentric? (15)

8.   DISORDERS    
(a) Outline a cognitive behavioural therapy as a treatment for one disorder (10) (b) Assess the effectiveness of treatments of one disorder (15)

Validity - What you need to know

What is Validity?
Validity refers to the extent to which a measure is measuring what it intends to, or in other words, it refers to extent to which it reflects the reality that it claims to represent. The first definition is more relevant to internal validity, whilst the latter helps to explain external validity.

How many types of validity are there? 
In short, loads. But out of ones that you should know at A-level, there's two categories, and a couple of types under each heading.

Internal validity: the extent to which a measure or test is measuring what it intends to. There are typically thought to be three main types:

1. Face validity - validity at face value, the simplest form. It's basically what gets affected by confounding and extraneous variables and lack of control over these factors. 

2. Construct validity - is the IV or DV appropriate for the concept being investigated? For concepts such as stress, this is a major issue. How do you define stress? And how can it be properly measured if there's no standard definition? One study which is relevant from the clinical psychology bit is Lewinson's study on positive reinforcements and depression - can you really measure depression levels on a depression adjective checklist? 

3. Concurrent (criterion) validity - do other relevant measures get the same result as yours? For example, if you're intending to measure intelligence through a new method, do the IQ scores or school performances of your participants correlate with the results you're getting?

External validity: the extent to which a measure or findings reflect the reality that it claims to represent. Again, there are 3 main types:

1. Ecological validity - refers to how realistic the task and environment is. If your task is similar to the real life behaviour it's attempting to measure, it's going to have high ecological validity.

2. Population validity - refers to how relevant the population is. If you're attempting to generalise your findings to all eyewitnesses, for example, you should ideally have a wide variety of real-life witnesses, who vary in age, gender, occupation, intelligence, ethnicity, etc.

3. Temporal validity - refers to how relevant the time period is in affecting the findings. e.g. A study on attitudes conducted decades ago cannot be expected to have temporal validity due to how quickly attitudes shift in society. 


All of these essentially link back to generalisability, usefulness and applicability to real life situations, so it's a really useful issue to get your head around, and worth mentioning if you can.

Reliability of Measures of Stress (Part B)

June 2011 - (b) Assess the reliability of methods of measuring stress (15)

Firstly, define the key terms in your introduction and outline the methods. You might also want to list some of the issues surrounding reliability.

"Stress is the body's response to when physical or perceived demands on an individual do not match their perceived or actual abilities to deal with a situation. It can manifest itself both physiologically and psychologically, and thus the most common approaches to measuring stress are physiological measures such as GSR, and self-report measures such as the Holmes and Rahe SRRS. However, the reliability of these measures is questionable, because of the changeable nature of stress, issues surrounding bias and standardisation, and confounding variables which mean that measures of stress may not always produce consistent results when the measure is replicated."

There's a lot of ways you could tackle the main body, such as doing one paragraph on internal reliability and one on external reliability, or going through different issues, but I prefer to go through measure by measure, and assessing each one's reliability. For example:

"One prominent measure of stress is the self-report method, which involves asking individuals to record either their stressors, such as their hassles and uplifts, or stress responses, as in the Bradburn Morale Scale. Whilst self-report appears to be an appropriate measures of psychological stress responses as it asks them about how they feel and what has bothered them, it is affected by many confounding variables that mean it's often not reliable. For example, two people may actually have the same number of hassles and uplifts, but individual differences such as the extent to which dishonesty, their mood, their memory, social desirability bias or interpretation affects their responses may result in them self-reporting different numbers of hassles. Thus, the measure may lack both internal and external reliability as well as internal validity for this reason. However, not all self-report methods lack reliability, and those with checklists or which ask closed questions may give more consistent results. For example, Holmes and Rahe's Social Readjustment Rating Scale (SRRS) involves a checklist, which is standardised and consists of the same life events. There is very little interpretation involved in answering the checklists which removes this confounding variable, and as stressors are listed in front of the individuals, poor memory is also less likely to affect the results. Thus, the measure is likely consistent over time, but may still have poor internal reliability due to the impact of mood and bias. Self-report measures are therefore variable in their reliability."

This paragraph includes examples, and a number of factors affecting reliability including standardisation, mood and subjectivitiy. It gives both strengths and weaknesses of the measure, thus fulfilling the "assess" part of the question, too. The result of my answer would consist of:

>> an assessment of physiological measures. I'd include objectivity as a strength, and that it's less affected by the user, but then say it's reliability is damaged by the fact that everybody experiences stress differently - some get headaches, some get muscle tension, others have increased heart rates, some do not experience it very much in terms of biology but their concentration lapses, etc. Also, different factors affect the physiological measures, such as in Geer and Maisel's study, GSR may not have merely measured stress response but other emotional responses, such as fear arousal or shock, and that heart rates as a measure can be affected by general health condition and exercise as well as weight, fitness, etc. 

>>briefly mention combined approach as seen in Johansson. Likely to share strengths and weaknesses of both, but may cancel out the influence of individual differences in terms of stress responses. 

>>Conclusion: both are replicable and thus should have external reliability, though stress is variable and thus the extent to which any measure can be considered to be consistent is questionable as it relies on a large number of variables to be controlled. 

The problems with diagnosing dysfunctional behaviour (and a great audio podcast on abnormality)

Here is an absolutely brilliant audio podcast from Todd Daniels, entitled "What is Normal?" He's a psychologist from the US, and he's got 50 audio podcasts on a range of issues. He explains things with plenty of examples, and I think it's definitely worth checking out. It's a little lengthy though, so here are some of the main issues:

Dysfunctional behaviour is a tricky term to define. Here's a working definition generally used by the psychology community:

It is behaviour which is deviant, maladaptive, and personally distressing. 

It fits pretty well with Rosenhan and Seligman's definition, too. Statistical infrequency, deviation from ideal mental health and deviation from social norms all links to the characteristic of "deviant", and failure to function adequately comes under both "maladaptive" and "personally distressing".

So, it seems like a great definition. But, there are limitations.

Not all behaviours considered dysfunctional have all three characteristics - so can they be defined as dysfunctional or abnormal? Sometimes. Smoking is an addiction, but unlike most addictions, it's not really considered dysfunctional, even though it's maladaptive and most find it personally distressing. On the other hand, depression is considered dysfunctional, even though it's likely more people suffer from depression than get addicted to cigarettes.

So, a major problem with diagnosing dysfunctional behaviour is not only defining it, but knowing how many characteristics of the definition behaviour has to exhibit to be labelled as dysfunctional.

Another problem is subjectivity, which leads to both poor validity and poor reliability. Whilst the DSM attempts to standardise diagnoses, the person who's diagnosing the disorder has room for subjectivity. For example, the DSM criteria for a phobia states that in order to be diagnosed, the fear of the object or situation must be "excessive". But, what's excessive? It changes according to the person. If the psychologist also fears the object, they might think there's a higher threshold for excessive than somebody who doesn't understand or share the same fear. So, a lot of diagnoses are actually based on bias of other people. Definitions also suffer from this weakness, as seen in the "observer discomfort" criterion for failure to function inadequately. Thus, there is unlikely to be uniformity in diagnoses, which leads to poor internal validity due to the confounding variable of bias, as well as poor reliability due to the individual differences of clinicians. 

Ethnocentrism is also an issue, related to this. Depending on our own culture, we may or may not perceive a behaviour to be abnormal. For example, if a man were to wear clothes such as dresses, or skirts, this in many Western cultures could be labelled as both deviant, and causing observer discomfort. It's statistically infrequent, and deviates from social norms. However, in Scotland for example, men wear kilts, which are essentially skirts. And, in the LGBT community, it wouldn't be considered abnormal. So, there's a fair amount of ethnocentrism within diagnoses. It's a fairly similar point to subjectivity, but you can extend it to points such as the fact that diagnoses cannot be generalised externally due to lacking population validity in other communities. They're also likely to lack temporal validity, due to the changing nature of cultures. Furthermore, it's arguable that the concept of dysfunctional behaviour lacks construct validity, as it's difficult to define. And thus, is it really nomothetic? 

Essentially, diagnosing dysfunctional behaviour is complex and often inaccurate. 

All the studies and theories for G543 (the ones I'm using)

Some people have been asking how many studies I've learnt, so I've put them all down here. It's also a bit of a reference point to see whether you're familiar with them or if you need to revise some sections more than others.

Forensic Psychology

Turning to crime

Upbringing - disrupted families [Juby and Farrington], differential association theory (learning from others) [Akers], poverty and disadvantaged neighbourhoods [Wikstrom and Tafel]

Cognition – criminal thinking patterns, [Yochelson and Samenow] moral development, social cognition (attribution) [both use Palmer and Hollin]

Biology – brain dysfunction [Raine], genes and serotonin [Brunner], gender [Daly and Wilson]

Making a case

Interviewing witnesses – recognising faces [Bruce], influencing factors (weapon focus)[Loftus] , cognitive interview [Fisher]

Interviewing suspects – detecting lies [Mann], interrogation techniques [Inbau], false confessions [Gudjonsson]

Creating a profile – top down [Mokros and Alison], bottom up [Copson], case study of John Duffy [Canter]

After a Guilty Verdict

Imprisonment – Planned behaviours [Gillis and Nafekh], depression/suicide risk [Dooley], prison situation and roles [Haney and Zimbardo]

Alternatives to imprisonment – probation [Mair and May], restorative justice [Sherman and Strang], looking death worthy [Eberhardt]

Treatment programmes – cognitive skills [Friendship], anger management [Ireland] and ear acupuncture [Wheatley]

Health and Clinical Psychology

Stress

Causes of stress – work [Johansson], hassles [Kanner], lack of control [Geer and Maisel]

Measures of stress – self report [Kanner], physiological [Geer and Maisel], combined approach [Johansson]

Managing stress – stress inoculation therapy [Meichenbaum], biofeedback [Budzynski], social support [Waxler-Morrison]

Dysfunctional behaviour/Disorders

Diagnosing dysfunctional behaviour – definitions [Rosenhan and Seligman], DSM, gender bias [Ford and Widiger]

Explanations of dysfunctional behaviour/disorders – faulty thinking (cognitive) [Beck], learned/positive reinforcements (behavioural) [Lewinson], serotonin and genes (biological) [Wender]

Treatments of dysfunctional behaviour/disorders – rational emotive therapy (cognitive) [Beck], CBT/behavioural activation (behavioural) [Lewinson], drug therapy (biological) [Karp and Frank]

Note that the two Beck studies and two Lewinson studies are different studies. The explanations one refers to studies where Beck interviewed patients with depression to see what cognitive distortions they shared, and Lewinson looked at positive reinforcements in the lives of depressed participants. In the treatments studies, Beck compares drug therapy and cognitive therapies, whilst Lewinson sees whether a "coping with depression" course coupled with parents being taught how to reinforce good behaviour is studied. 

Biological explanation of depression

Biological explanations of dysfunctional behaviour centres around physiology, and refers to aspects of biology such as genetics and brain functioning. 

The biological explanation of depression specifically refers to two factors: neurotransmitter dysfunction and inherited genes. In terms of neurotransmitter dysfunction, the biological approach would explain that depression is significantly associated with low levels of serotonin, which has been also been associated with many forms of dysfunctional behaviour including excess anger, anxiety, poor social functioning and other mood disorders. Serotonin is believed to have a variety of roles, and affects brain functioning; though it is not known whether depression is caused by serotonin levels, or whether depression causes low serotonin, or if there is another factor causing them both.

In terms of genes, family research - especially twin and adoption studies - has shown there to be a genetic link to depression, and that this suggests some people may carry genes that predispose them to depression and other mood disorders. Thus, depression could be explained in terms of genetic predispositions.

One study which conducted family correlational research into depression was Wender et al. It was an adoption study which looked at whether environment or genetics appeared to be more associated with depression in adopted adults. The study used a sample of 71 adults who had been adopted and who had a mood disorder, and 71 controls with the same mean age who'd also been adopted but did not have a mood disorder. All had been removed from their mothers at a young age. Psychiatric evaluations were conducted of both the biological and adoptive parents to see whether there was a stronger correlation between depression in adopted adults and depression in adopted parents or biological parents. The results showed that there was an eight fold increase in unipolar depression among the biological parents of the adults. In other words, adoptive parents were eight times less likely to have depression, and the biological parents having depression correlated more significantly with depression in the adopted children than the adopted parents having depression. 

Thus mood disorders appear to have a genetic link, and biological psychologists would thus attribute depression to genetics.