Section III - How to Improve Adherence

Attitude

As we have stated throughout this guide, if you as a health professional are willing to modify your behaviour and role beyond the medical model towards a partnership approach to your relationship with your patient, this will positively affect the patient's adherence to treatment.

'… patients need to know less about the pathophysiology of their disease and more about integrating new demands into their daily routine … (rather than to receive) … standard presentations of medical facts and treatment rules which all … asthmatics should know' (Mazucca 1982).

A commitment to partnership and a more equal relationship with your patient will foster communication and encourage the patient to take control of their self-management. This attitude should be based on a desire to understand the patient, their beliefs, their attitudes, their daily situation and schedule, and a non-judgmental attitude towards their non-adherence.

 

 

Focusing on the positive benefits of adherence, rather than the negative consequences of poor adherence, and devising practical strategies to address the impositions of treatment on the patient's life, will help to achieve a positive outcome. It is important to communicate to the patient that adherence will give them control, rather than asthma controlling them. If strategies or treatments have an unsatisfactory result, encourage the patient not to see it as a failure. Adverse reactions discourage adherence. Your attitude will help the patient to regard such incidents as learning experiences, rather than evidence that it's all too hard.

Approach

'In the past, the usual approach when discovering non-compliance is to attempt to persuade the patient of the error of their thinking and to try and communicate the intentions of the prescription and the importance of sticking to the regimen. Research strongly suggests that this approach has been of limited value' (Royal Pharmaceutical Society 1997).

We now know that the best approach when faced with non-adherence is to work with the patient towards a relationship based on knowledge and understanding, in which the patient's individual barriers can be discussed and addressed in an open, non-judgmental way that normalises non-adherence. As a health professional you know the medical and scientific reasons why your patient should adhere, but without communication, it is not possible to understand what leads your patient to adhere poorly.

Adherence can be promoted, identified and monitored by a collaborative approach to patient care by the asthma management team. Consider the strengths of the various members.

Pharmacists are in a unique 'front-line' position to assess and monitor a patient/client's adherence. Indeed the Australian Pharmaceutical Formulary states that 'the pharmacist must ensure as far as possible that the patient receives the required therapeutic effect of the drug'.

The pharmacist is an easily accessible and no-cost source of advice for the asthma patient. The pharmacist is likely to see patients on long-term treatment programs more regularly than their GP, and as we know, adherence decreases over time. Pharmacists can take these encounters as an opportunity to check or reinforce the patient's correct use of medications, provide education or advice, reinforce or clarify elements of the patient's management plan. If pharmacists see evidence of non-adherence or that the treatment plan seems unsuited to the patient they can refer them back to their GP for review.

Asthma educators are increasingly becoming valuable members of the asthma care team. Education is crucial to adherence, as well as to asthma management in general. More and more GPs are referring patients to asthma educators, who have the time and specific knowledge and skills to ensure patients understand their condition and their treatment.

 

 

The relationship between specialists and GPs has significantly changed over the past five years or so with both groups of practitioners now working together more effectively. For non-emergency cases requiring specialist attention, there can be issues such as long waiting lists. Recently, the approach taken has been for the GP to contact the specialist for advice, and then administer treatment within the general practice setting.

The NAC has been a driving force behind collaborative efforts in managing asthma and facilitating discussion between professional groups. The team approach to managing asthma more effectively is already happening with the result that health outcomes for people with asthma have improved (National Asthma Campaign 1998). Our latest challenge, to improve levels of adherence, will benefit from continued collaboration and alliances between health professionals involved in the asthma management team.

Strategies

In the next section you'll find practical suggestions to help you implement the following strategies in your work with people with asthma.

• Develop open, communicative, non-judgmental relationships with patients
• Normalise poor adherence in dealings with your  patient
• Adopt a partnership approach to asthma management with your patient
• Involve your patient in the planning process
• Simplify treatment where possible, and strive to tailor treatment plans to your patient's preferences, needs and capabilities
• Ensure that your patient understands their asthma and treatment
• Collaborate with other health professionals to improve patient outcomes
• Aim to build a partnership with patients for ongoing care
• Encourage regular reviews and ongoing monitoring of adherence levels
• Develop systems (such as reminders) to prompt patients on long-term treatment programs.

Practical Suggestions

Use appropriate information-gathering skills

It is possible to facilitate better communication with your patients by:

• using skills such as open-ended questions at the beginning of the consultation
• avoiding questions that elicit a yes/no response or that are judgmental in their tone
• showing empathy and warmth and following up on the patient's verbal clues.

Such communication strategies will make it easier to assess possible non-adherence, and make it easier for the patient to discuss their individual issues and barriers to good adherence.

Facilitate open discussions with your patient  about adherence

Your attitude and your manner will help your patient to be honest and realistic when you are discussing adherence to different treatments for asthma. It is important to be non-judgmental and to normalise poor adherence (remember, around 50% of patients don't adhere to prescribed therapy).

Ask questions that will elicit information about the patient's health beliefs, their attitude to their diagnosis and their willingness to make behaviour changes in order to better manage their asthma (see tips).

Use reminders

A number of prompts and reminders have been demonstrated to improve adherence:

• telephone or postcard reminders
• individualised reminder charts
• diaries
• engaging family members and carers to provide reminders

Facilitate recall

Health practitioners who use strategies such as repetition, giving specific advice, using written information, increase the recall of the patient. Knowledge of what to do is a prerequisite of adherence (Royal Pharmaceutical Society 1997).

Improve patient recall by providing written education material and a written record of medication names and doses.

Explain likely side-effects

One of the quickest ways to engender non-compliance with therapy is for a patient to experience side-effects about which they have not been forewarned. Discuss possible side-effects and suggest ways these can be minimised.

 

 

Always provide an opportunity for patients to express any concerns about the medication. Unvoiced concerns about continued drug use are a prime reason for discontinuing appropriate self-management. Give a balanced explanation of the benefits/risks of the medications.

Involve the patient in the planning process

One way to encourage regular review is to focus on short-term goals while highlighting the long-term objectives. Short-term goals set around patient priorities such as sporting participation or fewer days off school or work are more likely to be successful than physiological goals such as peak flow. Setting end points, where patients know that reaching a certain goal will result in changes to medication, may encourage regular review (Sawyer 1998).

With older patients, remember that the number of medications prescribed increases with age. The more medications used, the less likely people are to adhere.  As the numbers of medications prescribed increases with age, the elderly are particularly at risk (Australian Institute of Health and Welfare 1994). If possible, not more than 3-4 drugs should be given each day.

• Explain to the patient (or their parent/carer) that you are trying to make them more competent to manage the disease themselves - and that your role is as an adviser.
• Don't try to instruct patients in all aspects of asthma at one consultation - build their knowledge base over consecutive visits.
• Simplify medication regimens where possible.
• Use once or twice daily dosing whenever possible.
• Make sure the patient's Asthma Management Plan is in a written form that they can easily understand.
• Encourage patients to see you even when they're feeling well - adherence needs to be continually monitored over time.
• Emphasising disease severity will not necessarily make patients adhere better; helping them realise just how good they might feel is more likely to be successful.

Frequently Asked Questions About Adherence

1. I know that gaining a better understanding of my patients, and their beliefs and attitudes towards asthma and its treatment is meant to be important, but how do I do it and where do I find the time?

While an individual discussion of these issues may appear to take more time, research shows that consultations that use the communication skills referred to in this guide can lead to better health outcomes, more satisfied patients and shorter consultations. More satisfied patients will be more likely to return for follow-up, more likely to be honest and open in discussions, and less likely to require emergency management of asthma.

2. What's the most reliable way of finding out if my patients/ clients are adhering?

The accurate measurement of adherence is difficult. Although electronic devices, for use with medications and peak flow meters, do exist these are unlikely to be of practical use in the clinical setting. However studies show that patient admission of poor adherence is believable. Efforts to normalise poor adherence, the use of open ended questions and an information rich questioning style are more likely to allow people to admit less than ideal adherence. This can then be a starting point for identifying barriers and developing strategies to improve adherence.

3. How much adherence is enough? Is absolute adherence necessary?

We don't really know the answer to these questions. Our decisions about what treatment to prescribe are guided by the results from clinical trials. These trials provide us with information on health outcomes for a particular dose of medication. We aim for 100% adherence with the treatment regimen but we don't really know whether there is a meaningful clinical difference between patients who are 100%, 95%, 90%, 85% and 80% adherent to the regimen. We do know that adherence is variable, and often poor, and the more we can do to enhance adherence the closer we should move towards the health outcomes demonstrated through clinical trials.

4. Surely treatment regimens allow for low adherence. Could improved adherence create problems?

The objective studies of adherence have all been exactly that, research studies. These show regularly that adherence is only about 50%.  Therefore, participating in a clinical trial does not of itself result in good adherence, as was thought.  Consistent with this knowledge, drug studies generally use a 'run-in' period where patients who are not adherent with monitoring can be identified and do not participate further. The clinical benefits of improving adherence far outweigh any possible adverse effects.

5. What is the most important thing I as a doctor / pharmacist / nurse / asthma educator can do?

The most important thing that you can do is to work in partnership with your patient. This means that adherence is an issue for both of you. Sharing the responsibility for good management and asking yourself, 'how can I best help my patient to follow their treatment plan' is an important step. Ask the patient what aspects of their management concern them. These concerns may be personal or they may relate to you. Communicating and working together is the most important thing you can do.

6. Which is more important, explaining the medication or management plan better or actually simplifying the regimen?

Simplifying the regimen is likely to be more important in addressing adherence in the first instance. There is not much point to lengthy explanations about medications or plans if the regimen is too complex to deal with. The more frequent the dosing the less likely the drug will be taken. Also, different delivery devices can lead to confusion regarding best aerosol technique and result in poor drug delivery. Simplifying the regimen is an important first step which can then be built on.

7. Why would people with asthma be more inclined to adhere if they are a partner in deciding how to manage their asthma?

As a partner in the clinical situation the patient is able to communicate their views, feelings, concerns and take an active role in the outcome of the consultation. The input from the patient is used to guide the treatment regimen and so they themselves have crafted a plan or course of action for their own use. Ownership and control are important factors in ensuring the success of a self-management plan.

8. In theory I believe in self-management and shared responsibility but many of my patients couldn't cope with it. What's the alternative?

Some patients may appear to cope better with a more authoritarian style of communication. An authoritarian style may also appear easier for you the health professional, especially if this is your usual practice. However, this style of communication is not helpful in identifying patients with poor adherence. An interactive and open communicative style should be our goal, given that this is more likely to elicit poor adherence, the starting point for improved asthma outcomes.

9. How do I get through to the person with asthma just how important adherence is for them?

Encourage your patient to conduct their own clinical trial. Find out what health outcomes they would like to achieve and work out a course to accomplish these. It may just be that the patient has dropped themselves back to a level of adherence which provides them with the asthma control that they desire.

10. What skills do I need to develop?  What do I need to know and understand?

Communication skills mentioned throughout this guide are likely to be of most benefit to enhancing adherence. Being able to get patients to feel comfortable enough to express their attitudes, beliefs and concerns about asthma is likely to be an important starting point for dealing with adherence.

11. How do I manage this notion of an asthma care team? How important is it really?

The asthma care team is an important concept in the management of asthma. Members of the asthma care team include the doctor, pharmacist, patient, nurse and asthma educator. Much greater results can be achieved by a coordinated approach and teamwork. Patients who are supported by the asthma care team have a number of resources on which to draw to assist them to manage their asthma and to achieve the control they desire. By working together we can assist each other and the patient to minimise the impact of asthma.

Using Adherence Tools

There are various tools available to help you assess adherence. The following questionnaire is an example of structured means through which to better understand the person with asthma and to provide insights upon which to develop a manageable adherence regimen.

The Alfred's Asthma Education Profile Questionnaire (AEPQ) is designed in two parts. The first part explores the health beliefs (Maiman & Becker 1974) of the person with asthma and provides a framework for an educational context. It also provides an opportunity for the educator to address concerns and misconceptions the person may have about asthma. 

The second section allows identification of specific gaps in knowledge and skills necessary for effective self-management. This allows the educator to tailor the information to the needs of the individual, '...the information patients need is that which enables them to understand how to deal with their specific management problems' (Clark & Nothwehr 1997).

Administration Guidelines

The AEPQ takes 15 to 20 minutes to complete.

PART 1

• The issues raised in this section are best addressed at the time of administering the questionnaire¹.

PART 2

• Do not attempt to undertake any knowledge and skills education while administering the questionnaire.
• Any questions to which the patient's response is NO or UNSURE indicates a need for education, except question numbers i)d and ii)h where a YES response indicates a need for education.
• If more than one area or topic needs to be covered then prioritise and note in history/discharge summary/interim action plan.
• The order of priority should be determined by the doctor/nurse/educator undertaking the advice or education program. However, as a rough guide you may wish to follow this order:
  • signs of worsening asthma
  • following an action plan / peak flow monitoring
  • Medications
  • medication technique and delivery devices
  • physiology
• The Behaviour Change Protocol uses an empowerment approach. It is designed to ascertain the patient's views of their own progress, using prompts to help them find their own answers to difficulties. It is as applicable to other chronic diseases as it is to asthma and the original was developed for diabetes care.
• You may find it impractical to use such tools in your everyday work. However, they do provide a useful guide for the types of questions to be asked and how discussion about asthma and adherence can be approached in an open manner.

_{1. A response guide forms part of The Alfred Inpatient Asthma Education Program from which the AEPQ is drawn.}