Section II - Influences on Adherence
By now, it should be clear that there are many factors that influence a
patient's level of adherence. Adherence should always be evaluated within a
context, taking into account the behavioural and environmental factors which
impact on adherence.
The literature shows evidence for the following
factors affecting adherence:
Regimen on Complexity
Put simply:
- The more medications prescribed, the less likely they are to be taken.
One study measuring compliance with inhaled medication in asthma showed that
as medication dosing became more frequent the adherence decreased from 71%
twice a day to 18% four times a day (Coutts, Gibson & Paton 1994).
- The more frequent the dose, the less likely it is to be taken.
- The greater the interference with lifestyle, the less likely the patient
is to adhere.
Readability of Materials
The data about readability of information and instruction leaflets indicates
that many are too difficult for patients to understand. This has obvious
implications for adherence (Smith et al. 1998). It is important to be mindful of
a patient's level of education, cultural background, and literacy skills when
providing information.
Most people with asthma use their
medication as prescribed when they are symptomatic, as there is an immediate
connection between taking medication and the relief of symptoms. For the same
reason, adherence with reliever medication tends to be greater than adherence
with preventive medication. Once symptoms resolve, continued adherence becomes
increasingly difficult for many people with asthma (National Asthma Campaign
1998).
The Patient's Health Beliefs
People bring into the consultation their own beliefs and perceptions about
the illness. A study found that exploring these beliefs about the illness and
the benefits and barriers to taking medication and working with the patient to
come up with some sort of solution, led to better patient outcomes (Janz &
Becker 1984; Innui, Yourtee & Williamson 1976; Cockburn 1997).
| There is
some
evidence
that
compliance
decreases
when the
frequency of
dose
increases.
There is,
however, no
convincing
evidence of
an important
difference
in
compliance
levels
between one
and twice
daily
dosing.
Pullar
(1998)
concluded
that,
'...compliance
with the
once-daily
regimen was
best,
but...compliance
with a
twice-daily
regimen was
very similar
and both are
superior to
doing three
times a
day'. |
A number of studies describe marked differences between the beliefs of
patients and doctors about diagnosis and treatment. The
patient's so-called 'unorthodox' (i.e., different from the
current bio-medical) beliefs may well be unvoiced in the
course of an otherwise unremarkable consultation. It is
thought that these may be significant predictors of
non-adherence (Britten 1996).
Attitudes to Medications
Communication and open-ended questioning
are useful tools to discover a patient's
attitudes to medications and
medicine-taking, which will certainly
influence their adherence to treatment.
Sociological literature identifies the
following attitudes to medications in
many patients:
- the danger of becoming 'immune' over time
- the 'unnaturalness' of manufactured medicines
- the danger of addiction and dependence
- an 'anti-drug' attitude
(Royal Pharmaceutical Society 1997).
An Australian study suggested that in
some circumstances, non-adherence can be
seen as an active attempt by the patient
to reduce medication use. This has been
termed 'intelligent non-adherence'
because of the process through which the
patient is trying to do what the doctor
does, which is to manage asthma with the
lowest dose of drug possible (Toelle
1998).
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.
The Quality of Interactions between Health Professionals and
Patients
The quality of interactions between
doctor and patient can have a major
influence on health outcomes (Kaplan
1989; Toelle, Peat & Dunn 1998).
As stated, communication and
partnership, combined with flexible,
non-judgmental and pragmatic attitude,
lead to improved patient outcomes in
terms of adherence.
Psychological Factors
There is an emerging field of research which has identified psychosocial
factors as particularly important influences on adherence, and a risk factor
for asthma death (Rea et al. 1986). Broadly defined, these factors could be
psychiatric illness, drug abuse, intellectual handicap, denial of asthma
severity or social isolation. Psychosocial factors were found to have
contributed to the asthma episode in 86% of asthma deaths and 88% of cases
of near-fatal asthma (Campbell et al. 1992). Diabetes literature supports
the importance of psychosocial factors in adherence. There is evidence that
having a supportive family is associated with better self-management in
adolescence (Evans 1993). Adherence is also affected by the patient's
physical or social vulnerability (for example, being old, belonging to an
ethnic minority, suffering from a psychiatric illness) (Royal Pharmaceutical
Society 1997).
International research has also identified elements
which are not good predictors of adherence. There is a weak correlation
between the following demographics and the way in which medication is taken:
- age
- sex
- socioeconomic status
- severity of disease
- disease-specific knowledge
(Royal Pharmaceutical Society 1997).
Nevertheless it is clear that these factors and issues or factors should
still be taken into account when assessing a patient's adherence to
treatment, or devising a management plan. For example, here are some
thoughts about the influence of a patient's age
on their capacity/willingness to adhere
to treatment:
| '...the
best drug in
the world is
only as good
as it is
able to be
correctly
used.
(Sawyer
1998) |
Barriers to adherence by children
are compounded by their dependence on
parents (or carers) for the provision
and often administration of their
therapy. Communication with the parent
or carer is important so that you can
elicit their concept of asthma, which
has a powerful effect on therapy and
adherence. This concept will be
influenced by the parent's own
experience of asthma, and their
experience with family members or
friends. For children, the functional
status of the family plays a major role
in influencing adherence, for example,
the number of children in the family,
the number of parents administering
medication, issues of time management.
'...there
are still
many issues
of peer
pressure for
many
children -
avoiding the
use of
preventive
medication
at school
can help to
ease this
barrier.
There should
be regular
reviews to
update
children
with asthma.
It is
important
not only
that the
child has an
age-appropriate
delivery
device, but
as they get
older that
they can
actually
contribute
to the
decision
about
delivery
devices
used.'
(Robertson
1997) |
Young people develop increasing independence during adolescence
and want greater autonomy and control. They continue to require a variable
level of supervision and support from parents. The growing influence of
peers and the values they espouse has great significance during adolescence.
For some young people, the presence of asthma and the requirement for
regular medication acts as a barrier to participation in peer activities.
For others, the importance of establishing a regular routine for medication
has greater salience for adherence.
Young people can experience a conflict of priorities when it relates to
asthma management, such as the need to be socially acceptable to peers
versus the requirement to take regular medication. The influences on young
people's behaviours may not be obvious. For example, some young women are
too embarrassed to use their inhaler in front of boys because of its phallic
shape (Morsch, Stewart & Roller 1996). Clearly, gaining an understanding of
the young person's perspective, values and aspirations is a key goal for
health professionals if they are to influence health promoting behaviours.
While striving for the best health outcomes, health professionals should aim
for pragmatism not perfection (Bowes 1997).
'Many
young people
with asthma
are employed
part-time in
pubs or the
entertainment
area which
exposes them
to cigarette
smoke in
their work
environment.
Having a job
is often
more
important to
them than
avoiding
environments
which can
exacerbate
their
asthma.'
(Bowes 1997) |
Older people also have many
unique factors influencing their
adherence. Some studies have indicated
that 25-50% of particular groups of
elderly patients do not, or cannot, take
all their medications as prescribed
(Shimp 1985). Older people are more
susceptible to adverse reactions to
medications, which discourage adherence
(Williamson 1980). The issue of drug
interactions can also increase the
incidence of fear amongst the elderly
about the amount of medication they
take. Also, 20% of those over 85 years
of age have poor vision. Other factors
to take into account include: strength
and motor coordination; cognition (the
incidence of dementia is expected to go
up vastly over the next 20 years);
depression and isolation. Older people
also tend to under-report their
symptoms. The presence of other diseases
(such as heart disease) makes asthma
symptoms more difficult to identify
(Yates 1997).
The following factors do not have the
same level of concrete evidence from the
literature as proven influences on
adherence, but are still important
considerations
Social and Cultural Factors
One study found that people who had better family communication were more
likely to follow advice; we all know that family support is important. There
is some level of evidence from the psychiatric literature that by actively
soliciting family support, people might be more likely to adhere (Zhang et
al. 1994).
Doctor/Patient Communication
Goldberg (1983) found that when doctors used strategies such as
open-ended questions at the beginning of the consultation, showing empathy
and warmth and following up on verbal cues, it resulted in more accurate
diagnoses. Consultation styles do lead to more accurate detection and
assessment of non-adherence (Cockburn 1997).
Theories of Behaviour Change
Healthy behaviour can be seen as a means of achieving higher priorities,
or it can be seen as a constraint.
Adherence is not a high priority
for most patients. Most people are simply interested in getting on with what
they want to do in life, and hopefully not having their asthma interfere
with their ability to do that. One study of people with epilepsy (Conrad
1985) showed that patients' medication-taking behaviours were more
influenced by events in their daily routine than by their doctors' advice.
If poor adherence works for them, why should they change? The disruption to
routine, or reduced spontaneity that comes with some treatment regimens may
be seen as too great a cost for some patients, especially if the patient
does not identify any real benefits from adherence.
| 'Doin'
stuff'
'The Ziggy
Principle
was
formulated
by Bob
Kaplan
(1994).
Ziggy is an
American
cartoon
character:
to Ziggy the
meaning of
life is
'doing
stuff'. For
most people,
the Ziggy
Principle
informs the
way they
feel about
their lives:
doing stuff,
or our
capacity to
do things
and behave,
is more
important
than our
medical
'health
status'. For
most of us,
most of the
time, health
is a fairly
low
priority. We
see it as a
means to an
end so we
can do all
the stuff
that we want
to be able
to do.
People are
usually
trained to
optimise
their life
outcomes,
and most
people in
the health
field are
focusing on
trying to
optimise
health
outcomes. It
is worth
keeping in
mind that
the two are
not
necessarily
the same and
that your
goals may
not match
those of
your
patient.'
(Borland
1997) |
Models of individual behaviour change in psychology tend to focus around
what are known as expectancy value models, which an economist would call a
cost benefit analysis. Basically, it is a cognitive appraisal by the patient
- what's in it for me? - looking at the barriers of the costs, and comparing
them with the perceived benefits. For example, in terms of taking
medication, a child may perceive the benefit of earning the praise of her
mother, but also be wary that her friends at school will laugh at her if she
takes her medication, acting as a barrier.
Most models argue that
our beliefs lead to our behaviour. Many health professionals also know that
behaviour changes can also work on a patient's initially negative attitude:
'Just try it a couple of times, and see how it goes …' We need to find a way
to get patients to change their behaviour, by convincing them that the
benefits of adherence outweigh the costs, and devising practical strategies
so that the treatment plan fits in as neatly as possible with the patient's
lifestyle and aspirations.
Patient Attitudes
A qualitative study from Canada explored patients' experiences of asthma.
It found that initially patients identified two key feelings: loss of
control and fear. The process of overcoming these feelings and moving to
acceptance and having the asthma controlled, rather than being controlled by
the asthma, came through knowledge, self awareness and experience,
facilitated by a mentor (Snadden & Brown 1992).
Personal Risk Management Strategies
There is some evidence that patients themselves attempt to analyse their
positive and negative perceptions about the medicine and carry out their own
cost-benefit analyses (Donovan 1992). This may then manifest as poor
adherence.
