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Overview: Issues in measuring adherence to therapy for short- and intermediate-term infections

Overview: Issues in measuring adherence to therapy for short- and intermediate-term infections Susan Zimicki AED/CHANGE Project. Not a review. Not a lot of data Where it exists, with few exceptions,quality unclear/suspect Not very informative: Incomplete courses

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Overview: Issues in measuring adherence to therapy for short- and intermediate-term infections

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  1. Overview: Issues in measuring adherence to therapy for short- and intermediate-term infections Susan Zimicki AED/CHANGE Project

  2. Not a review • Not a lot of data • Where it exists, with few exceptions,quality unclear/suspect • Not very informative: • Incomplete courses • Not purchased - affordability • Stopped because better or no change • Wrong dosing (malaria)

  3. Adherence Patients should take • (just) Enough of the right drug to get cured • In a way that minimizes the chance of development of resistance

  4. Operational definition • Right drug for the infection • Right amount • dose (formulation), total duration, intervals • Right circumstances • e.g., with or without (certain) food, not with certain other drugs

  5. First issue: Ideal behavior • In many cases, it is not clear what ideal behavior is • The problem: “right amount” • Where researchers have looked, many antibiotic regimens are unnecessarily long • Cure can be achieved with shorter courses

  6. Implication: • Frequently-used definition: Patient took the drug • As recommended by provider, or • According to instructions on packaging • Measures • Effectiveness of communication • Ability to follow instructions (if any) • Not adherence per se

  7. Based on: Observation Reports Concurrently recorded Recall Artifacts MEMS Pill counts Used blister packs Issues Difficulty Validity, reliability Completeness Most frequently used measures of adherence

  8. Second issue:Measures do not inform interventions Need to change the question From: What did the patient do? To: Could/can the patient do it right? Measure knowledge, skills, attitudes that are necessary for adherence

  9. Partial behavioral analysis: • Get right drug Available, affordable, know brand • Get right dose Know weight, age, interpret pictures • Measure dose correctly Right # tablets Split tablets accurately For liquids – right spoon size • Swallow Taste, tablet size acceptable

  10. More… • Get timing right Know right time/interval Be able to estimate, remember • Get duration right Know # days Know finishing is important Persist even if symptoms disappear Persist even if side effects (manage them) But stop if there are severe side effects

  11. Another “behavior analysis scale” Behavior change and maintenance are affected by: • Immediate positive consequences • Complexity • Frequency • Cost of engaging • Persistence required • Compatibility with existing practices • Observability

  12. Positive consequences Expectations about symptoms and side effects are key • Symptoms • Perceived efficacy related to • Time to onset of symptom relief • Time to complete resolution of symptoms • Side effects • Some are expected and tolerated • Some unexpected and managed • Some not tolerated

  13. Other factors likely to be important: • Belief/doubt about source • Self-efficacy • (Autonomy) • Compatibility with existing beliefs and conventions • Color, taste, timing, number

  14. Measurement • Most factors easily measured • Experience with validity & reliability • Most can be informative when measured on a population basis (not just currently/recently ill) • Easier sampling • But triangulation desirable • Results can inform interventions

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