Health Psychology

1. Health Psychology Adherence

2. Requirements • Why we don’t • Measuring • Improving • Use the first 4 or last 3 studies

3. Background • ADHERENCE • Adherence rates requiring medicine for long or short term illness = 60%. But if a diet or exercise/lifestyle change needed compliance is lower. • CUSTOMISING • Follow advice reasonably closely but make an attempt to get it to fit with lifestyle • RATIONAL NON-ADHERENCE • Choosing not to comply – may not have a belief in the benefits, treatment causes suffering, confusion, practical barriers (cost), is illness still there when medication isn’t • LOCUS OF CONTORL • Personal choice or little influence over what is happening. More they feel in control more likely to adhere. • SELF-EFFICACY • A belief they will be successful in what they do and given the means to be capable too. • DOCTORS AS PATIENTS • Shouldn’t self prescribe but 70% do. Shouldn’t treat family members – 80% do

4. Background 2 • TYPES OF REQUEST • Short term adherence (3x a day for 3 weeks); lifestyle (eat more fruit); stop (stop smoking); long term regime (diabetic diet, renal dialysis) • MEASUREMENT • Self report – ask. Patients overestimate • Therapy outcome – getting better. Other factors may affect • Health worker estimates – unreliable • Pill count – how many thrown away? Random raid? • Mechanical method – devices on bottle; measure how many taken out, but not how many taken • Biochemical test – blood/urine test

5. Background 3 • IMPROVING • Old people have different understanding and can’t follow complex instructions • Containers are difficult • Large ranges of treatment increase side-effects • PRESENTATION • Simple verbal instructions • Specific not general • Smaller steps • Key information emphasised • Simple written • Repeat in own words • MEMORY • Structured/categorised information easier to remember • Primacy effect • Repetition does not improve recall • Some medical knowledge helps • TECHNICALITIES • Baffle and intimidate • If not understood or recalled then unlikely to adhere • DOT • Direct observation of patient taking medication

6. 3 Short Summaries • We don’t always do as we are told by health workers (or mothers). At first glance this appears to be lazy or even reckless, but careful closer consideration shows many health choices we make are a common-sense way of dealing with the many influences on us • Measuring behaviour is difficult at the best of times. Measuring behaviour such as treatment adherence, often done in private, is even more difficult. The various methods used, however, probably give a fair idea of how much people follow medical advice. • People can be encouraged to be more adherent through a variety of methods. The more successful ones include improving available information, watching people take the medicine, and threatening with prison.

7. Adherence – Study 1 • Sethi et al • Who • 2003 • Drug adherence to antiviral therapy & resistance • Correlation, longitudinal • 195, 32-48yrs, HIV Moor clinic – restricted cluster (criteria met – drugs prescribed, low HIV load, no drug mutations, no viral failure) • Paid & informed • What • Visit following clinic appointments • Cumulative adherence measured using formula (prescribed – missed / prescribed) and categorised • HIV load tested – independent, experienced, blind tester – if greater than 500 loads then resistance • Results • 14% developed resistance • 66% no resistance; 19% not followed up (death, prison, discontinuation, attrition, transfer) • Cumulative adherence 70-89& shows significance with resistance to drugs. Outside this range no correlation with resistance. Bell shaped distribution of adherence and drug-resistance

8. Adherence – Study 2 • Yung • Who • 1998 • Age and knowledge and relationship with adherence • 56 men, 70 women, 50-82 years, diabetic, clinic, HK, cluster sample. Natural experiment • What • 7 weeks informed consent, interviewed by 1/3 pharmacy studnets under supervision ½ doctors. • Data includes age, sex, duration of & treatment, attendance at classes, presence of complications, attacks, other conditions, blood glucose, renal, liver function tests. • 2 validate questionnaires. 1 – knowledge of conditions and adherence – what is wrong with your blood glucose, what do the tablets d, meals, miss meal, too many, dizzy, card carried, attack, sweets, relatives. 2 – measure knowledge of symptoms of attack – yes, no, don’t know, list given • Read if illiterate/visually impaired, care not to ask leading questions • More correct answers = greater knowledge/adherence • Results • Significant decline in correct answers given to knowledge as age increased, but only to half of adherence questions. Significant decline in knowledge of symptoms with age (except tingling lips) • Previous experience of attack had no effect on knowledge • If never attended classes then scored lower on all variables (knowledge of diabetes, knowledge of attacks, adherence) • More recent attendance correlated higher scores

9. Adherence – Study 3 • Watt et al • Who • 2003 • Funhaler – asthma made fun • Experiment • 10 boys, 22 girls, mean age 3.2y • All prescribed drugs via inhaler • Informed consent from parents • What • Standard inhaler in week 1. Funhaler week 2 (toys, spinner, whistle – distracts and reinforces correct delivery, doesn’t interfere, can be replaced if bored) • Adherence measured via parents questionnaire frequency and regularity of use • Results • 27/32 completed questionnaires. 38% administered Funhaler more regularly, 60% more children took recommended cycles

10. Adherence – Study 4 • Sharma • Who • 2003 • Adherence to food pyramid by ethnic groups • Natural experiment, 115000 people 45-75y, ethnic groups (American, Japanese American, Hawaiian) quota sample, informed consent • What • Questionnaire – food frequency questionnaire, standardised before use • Self administered postal. Asks how often foodstuffs eaten over 3 days, covered 85% intake of fat, fibre, vitamin A, carotenoids, vitamin C, measured in servings and converted to calories. Traditional foods to ethnic groups covered even if nutritional value not relevant • Results • Data for each group compared to recommended intake. Little variation between ethnic groups and adherence – no one adhered more than any other group. If calorie intake below 1600 per day (regardless of ethnicity) then food groups missed out (usually dairy) 58% of time. If calorie intake above 2800 (no ethnicity associated) then 3x alcohol, more fat and added sugar • Between groups – Hawaiians had highest daily calorie intake and high BMI, ate most daily servings of food groups with exception of dairy. Japanese-Americans had low BMI but the men ate 2 more servings per day of grain than white men.

11. Study 5 • DiMatteo • Who • 2000 • Depression is risk factor for non-compliance • 25 studies, 68-98, 12 about depression, 13 about anxiety • What • Studies measure adherence and depression/anxiety but not being treated for depression/anxiety – reviewed results • Results • No correlation between anxiety and non-adherence but strong correlation between depression and non-adherence • Compared with non-depressed patients, depressed patients are 3x more likely to fail to adhere

12. Study 6 • Choo et al • Who • 2001 • Risk factors for over-reporting adherence • 286 (age 18-84, 50% female, 33% black, 67% graduate) on anti-hypertensive therapy • What • Baseline questionnaire – socio-economic status, medication, adherence, health beliefs, health status, social support. • 3 months monitoring – adherence question – while using special bottle how many days in average week did you forget to take a pill? Actual adherence measured by electronic monitoring vial. Informed about purpose of electronic medication monitor • Results • 21% admitted missing 1 or more days a week – but true figure 42%. Over-reporters tended to be from lower socio-economic background, lower health risk, and taking more than one daily dose

13. Study 7 • Lustman • Who • 2000 • Depression in diabetes • Treat depression and see if adherence improves • 60 patients diabetic and major depression; advertisement 2 centres (screened out suicidal, bipolar, psychotic) • What • Randomly assigned 2 groups. 1 – received antidepressive drug other placebo. Double blind. Over 8 weeks daily dose of antidepressive given and depression measured (2 known scales). Blood sugar monitored as a measure of adherence to medical regimen • If still depressed after 8 weeks referred for therapy • Results • Antidepressive patients less depressed and showed healthier blood sugar levels

14. General Review • Ethics • Maintain confidentiality, informed consent, withdrawal rights, harm minimised etc • Sharma & Watt some withdrawal seen • All informed (parental in Watt) • Minimised harm – Funhaler designed to deliver drugs without affect • Sethi & Yung, identified non-adherence factors but did nothing about it! • Reliability/Validity • Validity – measure what we think we are • Reliability – able to measure it consistently • Sethi – straightforward but face validity (no predictive validity) • Sampling • Sharma – very large numbers involved, so ethnic groups well represented • Sethi – what if a different drug was used? Or a different medical condition • May limit ability to generalise but also allows us to discuss factors • Usefulness • Reveal why people do not adhere – therefore improve adherence • Sharma – adherence to diet to develop programs for obesity • Different groups require different approaches • Need to be fun – Watt • Cognitive memory aids needed - Yung

15. Questions • Describe one study of why people do not adhere to medical advice (6) • Evaluate research into non-adherence to medical advice (10) • Describe one way of measuring adherence/non-adherence (6) • Discuss validity of measures of adherence/non-adherence (10) • Describe one way of improving adherence (6) • Discuss problems of improving adherence (10) • Describe what psychologists have found out about why people do not follow medical advice (10) • Discuss the psychological evidence on the reasons why people do not follow medical advice (16) • Suggest one technique that could be used to encourage children to use their asthma inhalers more regularly. Give reasons for your answer (8)