Improving adherence.

Summary

Provide more information about the drugs and the treatment.

Tailored regimens are easier to comply with, and there has been some encouraging results (e.g. Haynes et al, 1979).

Get the doctor to improve communication and to be warm and sensitive.

Get the patients to ask more questions so that they get more information. This will help to prevent false beliefs. It also improves patient satisfaction with the doctor, and thus compliance. Some patients may not know what to do if they miss taking some tablets. Others may not know when they could expect to feel better.

Three different types of leaflets were given to patients. One was easy to understand, another was moderately difficult and the other was very difficult to understand. Compliance increased for those patients who were given easy or moderately difficult leaflets (Ley et al 1976).

Just informing patients about their illnesses will not necessarily increase compliance. Patients suffering from hypertension viewed a slide show and read a booklet about hypertension and its treatment, emphasising the benefits of treatment and regular medication. Despite this greater understanding there were no differences in compliance or effectiveness of blood pressure control between patients who had and had not been given the educational program. However, programs that provide information about the problems people will face in trying to adhere to a regimen and focus on changing peoples interpretation of their relapses have been more successful in promoting compliance (Belisle et al, 1987).

Increase the frequency of visits to the doctors. This would increase positive reinforcement. The patient would comply because they would not wish to be scolded by the doctor. Some studies have found compliance to increase by up to 60 percent (e.g. McKenny et al., 1973). When supervision is reduced, so is compliance. For example, non-compliant hypertensive patients were asked to keep a record of their blood pressure and compliance was increased as a result. This only happened when the records were checked on a regular basis.

Nessman et al (1980) group sessions are more effective. In this experiment the treatment was for hypertension (high blood pressure). Compliance increased from 38% to 88%. The result could be misleading because the researchers were only able to persuade 56 people out of a possible 500, to take part! They could have been highly motivated from the start!

One factor that might improve adherence is designing information sheets and treatment programmes that are easy to understand and carry out. An important aspect of this is to consider the special needs of different client groups. Old people, for example, often have different understandings and health beliefs to young people. Kaplan et aI. (1993) identifies three problems for old people in following treatment programmes:

i)      Some old people have difficulty understanding and following complex instructions. Although ageing is not necessarily related to mental decline, some old people develop cognitive problems, such as memory loss, which make it more difficult to follow treatment programmes.

ii)     Older people sometimes have difficulty with medicine containers because they lack the manual dexterity to deal with childproof caps. It has been noted that older people sometimes get over this problem by transferring the tablets to other containers, and this can lead to confusion about which tablet is which.

iii)    Older people are sometimes on a range of medications for different conditions and these might be prescribed by different doctors. This increases the risks of unpleasant side-effects, and so increases the chance that the patient will decide to discontinue the treatment.

Improving communication

(Sarafino 1994)

  1. Simple verbal instructions, simple language (no jargon)
  2. Give specific instructions, not general ones
  3. Emphasise key information
  4. Give simple written instructions
  5. Get the patient to repeat the instructions in their own words.
  6. Break down the information into stages. get the patient to follow a simple regimen at first, and then add to this later.

This will help for short-term regimens more than long-term (Haynes, 1982).

Kulik and Carlino (1987) found that by getting children to promise to take the medicine, significantly more children complied as ascertained by urine samples and interviews with parents. Control children were told to take the medicine, but the doctor did not ask the child to promise. The children were randomly allocated to the two groups. The children were followed up 10 days later.

The health worker has a central role. They can tailor the message to the individual lifestyle of the patient. Face to face contact will increase co-operation. Can get other family members to help out. Progress can be monitored.

Behavioural methods

  1. feedback - regular reports can reinforce compliant behaviour.
  2. Self-monitoring - patient keeps a written record
  3. Tailoring the regime - fitting in the treatment with the patients lifestyle.
  4. Increasing sense of control.
  5. Prompts and reminders - using alarm settings on a watch or telephone calls to remind patients.
  6. Contingency contract - goals and rewards negotiated with health worker
  7. Modeling - patient can see other patients successfully following their treatment.

Major advantage is that patients can become involved in their treatment (Turk & Meichenbaum, 1991).

MEMORY

The material covered in diagnosis and style is relevant here.

 

DIRECTLY OBSERVED THERAPY (DOT)

The direct observation of patients taking their medicine is a strategy used to improve completion rates of tuberculosis treatment. It was first introduced over 40 years ago, and is still extensively used around the world in various formats. Adherence to the treatment programme is especially important in tuberculosis because of the seriousness of the disease, the ease with which it spreads, and the danger of the medicines becoming ineffective through resistance. A review of 32 studies of DOT programmes since 1996 found that most reported improved adherence rates — though the many extra features of the studies might well have contributed to these results (Volmink et al., 2000). The extra features of the programmes included reminder letters to clinics and financial incentives. In one programme in the USA, patients received the equivalent of $100 a month to continue with the programme. This might appear generous but it should also be noted that in New York the law was changed so that people could be required to take the treatment or face compulsory admission to hospital or imprisonment. This seems to be an effective, if brutal, way of encouraging adherence. In some studies, the important factors were social variables such as friendly relationships between staff and patients. The review concludes by suggesting that many studies concentrate on DOT as the active ingredient of the adherence programme, but that it might well be that the other factors (such as incentives) have a greater effect.

Text Box: Improving adherence to malaria treatment for children: the use of pre-packed chloroquine tablets vs. chloroquine syrup Ansah, Gyapong, Agyepong and Evans Tropical Medicine & International Health, Volume 6, Number 7 (July 2001) Malaria is a major cause of morbidity and mortality among children under five in sub-Saharan Africa. Prompt diagnosis and adequate treatment of acute clinical episodes are essential to reduce morbidity and prevent complications and mortality. In many countries, chloroquine syrup is the mainstay of malaria treatment for children under five. Not only is syrup more expensive than tablets, adherence to the prescribed dose at home is a problem because mothers use wrongly sized measuring devices or have difficulty with the instructions. We investigated the impact of introducing pre-packed tablets for children on adherence to treatment and compared the total cost of the tablets with that of syrup. Children aged 0–5 years diagnosed with malaria at the clinic over a 6-week period received either pre-packed tablets or syrup by random assignment. The principal caregivers were interviewed at home on day 4 after attending the clinic. Of the 155 caregivers given pre-packed tablets, 91% (n=141) adhered to the recommended dosage, while only 42% (n=61) of 144 who were provided syrup did. Only 20% of caregivers who received syrup used an accurate 5ml measure. The cost of treatment with tablets was about one-quarter that of syrup and 62% (n=96) of caregivers preferred tablets. Pre-packed chloroquine tablets are a viable alternative to syrup. Advice to parents of children with AIDS
Encountering the health care system - click here for relevant lecture notes
The Compliance and Adherence Process in the Transplant Patient: Professional Responsibility Bonnie Siegal, PhD, NASW Diplomate

Louise Ellerby-Jones with some tips for teachers and students

Source

Philip Banyard, 2002, Psychology in Practice – Health, Hodder & Stoughton, ISBN 0-340-84496-5


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