Medical compliance as an ideology

Problems of nonadherence in cardiology and proposals to improve outcomes

At least 1 in 7 cardiology patients now reports nonadherence to prescribed medications, potentially leading to negative outcomes across a broad range of cardiovascular diseases. This nonadherence can begin as early as the time of prescription or any time thereafter and occurs for a variety of reasons, including communication difficulties, polypharmacy, and a variety of objective and perceived side-effects. Among elderly, low-income, and disabled patients, drug costs represent a growing source of medication nonadherence and can be markedly reduced through the use of drug assistance programs and low-cost generic medications without sacrificing evidence-based therapy. Depression also contributes strongly to nonadherence and is widely prevalent in cardiovascular populations. Improvements in depression are mirrored by improvements in adherence. A systematic screening to identify the presence of nonadherence and many of its causes can be accomplished with minimal impact on visit length. In conclusion, once specific concerns are recognized, options frequently exist to help patients and providers address many of the most common difficulties.

From consumerism to active dependence: Patterns of medicines use and treatment decisions among patients with atopic dermatitis

In this article, findings from in-depth interviews with 12 people diagnosed with atopic dermatitis (AD) are described. The findings describe the range of strategies used to manage atopic dermatitis, including use of conventional medicines. A strong theme identified in informants' accounts centred on concerns about the risks of illness and long-term use of conventional medicines, which acted as a strong incentive for patients to seek alternatives to conventional treatments. However, despite their significant efforts to do so, patients were eventually forced to return to and rely on conventional medicines because of their efficacy in alleviating and treating symptoms. These findings are discussed in relation to the sociological literature on consumerism, risk and reflexivity in health. We argue that our findings exemplify how living with and managing a chronic illness may not be straightforward and the choices of treatment at hand may be limited. Consequently, this may limit the potential opportunities accruing from adopting a reflexive or consumerist approach to managing illness.

Restraints and the code of ethics: An uneasy fit

This article examines the use of physical restraints through the four broad principles of ethics common to all helping professions. It asks whether the continued use of physical restraints is consistent with ethical practice through the lens of those principles. It also examines where the necessity to use restraints in the absence of empirically supported alternatives leaves professionals in terms of conflicts between ethical principles and makes recommendations for changes in education and clinical practice. It concludes that an analysis through a bioethics lens demonstrates that the use of restraints as a tool in psychiatric settings is a complex and multifaceted problem. Principles of ethics may often be in conflict with each other in instances where patients must be physically restrained.

Self-management for breathlessness in COPD: the role of pulmonary rehabilitation

Most of the effort of controlling breathlessness happens at home. Therefore, it is important to explore how patients and carers respond to breathlessness, what their self-care entails and what they experience as helpful. Data were collected from a purposive sample of 18 chronic obstructive pulmonary disease patients through participant observation during outpatient consultations and in-depth interviews at a large hospital and in the community in London. Data were analysed with the Grounded Theory approach. As information regarding the management of breathlessness was lacking and access to treatment was difficult, patients reverted to alternative strategies. Some patients developed considerable expertise and managed their symptoms competently within the limits of current care. Patients who coped successfully were involved in pulmonary rehabilitation and had adopted this as a way of life. Benefits and challenges to participation in these programmes were identified. Those patients who self-manage maintain an acceptable quality of life through self-acquired expertise relating to symptoms, medication and help-seeking. Well-being needs to be understood not as the end point, but as a precarious balance needing skilful maintenance and hard work. The findings have implications for notions such as adherence, patient involvement and responsibility in the management of chronic obstructive pulmonary disease.

'Consumers are patients!' shared decision-making and treatment non-compliance as business opportunity

This article describes an aspect of the progressive insertion of commercial interests into the relationship between patients and their clinicians, with particular reference to psychiatry. Treatment noncompliance, a long-standing problem for healthcare professionals, has lately drawn the attention of the pharmaceutical and allied industries as a site at which to improve return on investment (ROI). Newly founded corporate ;compliance departments' and specialized consultancies that regard noncompliance as a form of marketing failure are seeking to rectify it with reinvigorated models and strategies. This intervention stands to impact patients' experience of illness as well as the participation of those formally (physicians, case managers, etc.) and informally (family, friends, etc.) involved in treatment. My analysis draws upon observation at compliance conferences to demonstrate the contrasting models of patient empowerment underlying the marketing vs. medical approaches. I propose a research agenda for measuring the effects of industry compliance programs.

The transition from children's to adult diabetes services: understanding the 'problem'

AIMS

The importance of getting transition right for young people with diabetes is increasingly recognized and a strong professional consensus has emerged on best practice in this domain. Research evidence to inform the design of transitional healthcare services is weak, however, and prevailing views about 'the problem of transition' are based on a number of assumptions about adolescence, adulthood and chronic disease management which have been accepted uncritically.

METHODS

Drawing on youth studies and the sociology of chronic disease management, in this paper we describe how 'the problem of transition' has been defined in the professional and UK policy literature and examine the assumptions that underpin it.

RESULTS

We argue that the overwhelming emphasis is on how best to support young people in fitting in with the healthcare system. This has produced an orientation which is more concerned with supporting young people in the process of becoming adults rather than giving attention to their contemporaneous experiences and needs. Two years after the introduction of the UK National Service Framework for diabetes, the challenge of transitional services remains.

CONCLUSIONS

We suggest that the time has come to consider alternative formulations of the 'problem'. Rather than asking how best to manage transition, we might ask how best to meet the needs of young people with diabetes at this stage of the life course. This requires an understanding of their experiences, the social networks in which they are embedded and consideration of how self-management might be supported by the healthcare system.

Exploring tuberculosis patients' adherence to treatment regimens and prevention programs at a public health site

Our aim with this study was to explore the factors that contribute to tuberculosis patients' adherence and nonadherence to the Directly Observed Treatment Short Course strategy. A qualitative, phenomenological research design was used. Fifteen male and female participants between the ages of 18 and 57 years were recruited through purposive sampling at a primary care clinic located in a disadvantaged area, and in-depth interviews were conducted. The data analysis indicated that the factors found to influence adherence were social and economic resources; causal attributions assigned to TB; the social, cultural, economic, disease-related, and psychological challenges faced as a consequence of having TB; quality of health care received; use of the traditional healing system; and the participants' HIV status. Factors found to be associated with nonadherence included poverty, HIV co-infection, stigma, unsupportive social and work environments, and a high prevalence of helplessness and hopelessness.

Time, self and the medication day: a closer look at the everyday work of 'adherence'

This article examines the everyday work of participating in pharmaceutical treatment for HIV infection in the context of urgent calls for adherence. Drawing on interviews and focus-group conversations with people taking antiretroviral drugs, the analysis explicates the work that goes into striving for adherence. What comes into view is a form of time work that brings about a temporary alignment between the inner experience of time, standard clock time, and the requirements of the medication schedule. Time work is largely cognitive; the pills, however, must actually be swallowed to complete the dose, occasioning, for some people, additional work to suppress or refashion emotional responses of anger and resistance. Both the time work and the emotional work of taking antiretroviral drugs draw people into forms of self work, including self-examination and self-adjustment, as they develop strategies for 'doing adherence'.

Produção bibliográfica sobre adesão/não-adesão de pessoas ao tratamento de saúde

Análise crítica da produção bibliográfica latino-americana dos últimos dez anos, acerca da adesão/não-adesão ao tratamento de pessoas portadoras de problemas crônicos de saúde: hanseníase, tuberculose, hipertensão, diabetes e aids. Foram analisados 36 artigos, identificando-se as variáveis: ano de publicação, área de publicação e tipo de estudo. A maior parte dos artigos (27) foi produzida por profissionais da área de Medicina em estudos epidemiológicos e da área de Enfermagem (7) em estudos qualitativos e quanti-qualitativos. A produção científica sobre o assunto cresceu até 2002, caindo a partir desse ano. Nas definições descritas pelos autores, a idéia recorrente foi a de que o papel do paciente é o de ser submisso às recomendações dos profissionais de saúde e que ele tem autonomia para seguir ou não o tratamento, mas o profissional exime-se da responsabilidade sobre as conseqüências dessa decisão. A maioria dos fatores apontados pelos autores como contribuintes para a não-adesão está relacionada ao paciente, mostrando que a maior carga de responsabilidade pela adesão/não-adesão é conferida a ele. As medidas assinaladas pelos autores para a resolução do problema permitem a identificação da responsabilidade dos profissionais, serviços de saúde, governos e instituições de ensino.

Adherence: a concept analysis

AIM

This paper is a report of an analysis of the concept of adherence.

BACKGROUND

The transition in terminology from compliance to adherence, and more recently to concordance, requires re-clarification of 'adherence' as a concept in nursing practice. Differences exist in the use of the term adherence and how or if it differs from compliance or concordance.

DATA SOURCES

Using the Medical Subject Headings terms adherence, non-adherence and treatment refusal, the Cumulative Index to Nursing and Allied Health Literature, Medline, PsychINFO and Cochrane library databases were searched for publications between 1970 and 2007. Method. The evolutionary analytic method was used to identify and explore transitions in the concept of adherence over time and across healthcare disciplines. A representative sample of papers was identified from the disciplines of nursing, medicine, psychology and pharmacy.

RESULTS

We identified 114 papers: 27 from nursing, 39 from psychology, 33 from general medicine and 15 from pharmacology sources. The final sample included eight from pharmacy and 15 from mental health, medicine and nursing. We found no distinct differentiation between adherence and compliance. The surrogate terms serving as manifestations of adherence are concordance, agreement, cooperation and partnership. The most common definition found was as follows: 'Adherence can be defined as the extent to which patients follow the instructions they are given for prescribed treatments'. No definition of adherence exists that reflects a patient-centred approach, the dynamic nature of adherence behaviour and the power imbalance implied by these terms.

CONCLUSION

This concept analysis of adherence is a preliminary step towards broadening nurses' appreciation of the complexity of patient adherence behaviour.

The "medication interest model": an integrative clinical interviewing approach for improving medication adherence--part 1: clinical applications

PURPOSE/OBJECTIVES

Medication adherence is a major problem in healthcare today. The medication interest model provides a variety of interviewing techniques for achieving positive outcomes regarding medication adherence.

PRIMARY PRACTICE SETTINGS

The model is applicable to all primary care settings as well as specialty areas from endocrinology and cardiology to psychiatry.

FINDINGS/CONCLUSIONS

The medication interest model includes more than 40 behaviorally well-defined interviewing techniques. These interviewing techniques are housed within a conceptual framework, the Choice Triad, designed for the sensitive exploration of the thought processes and emotional responses patients experience when using medications.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The model holds the promise of providing 1. interviewing techniques and strategies for immediate application by case managers for improving medication adherence; 2. a practical conceptual umbrella for the integration of well-established collaborative interviewing principles, such as the principles of motivational interviewing, with new interviewing techniques created by case managers in the field; and 3. a platform for the development of research studies and training protocols consistent with evidenced-based educational innovations in teaching clinical interviewing skills such as microtraining, macrotraining, and the use of competency testing.

Beyond decision making: class, community organizations, and the healthwork of people living with HIV/AIDS. Contributions from institutional ethnographic research

The consolidation of antiretroviral therapy as the primary biomedical response to HIV infection in the global North has occasioned a growing interest in the health decision making of people living with HIV (PHAs). This interest is burdened by the weight of a behaviorist theoretical orientation that limits decision making to individual acts of rational choice. This article offers an alternative way to understand how PHAs come to take (or not take) biomedical treatments. Drawing on institutional ethnographic research conducted in Toronto, Canada, it explores how the "healthwork" of coming to take (or not take) treatments is organized by extended relations of biomedical knowledge. The article focuses on two aspects of the knowledge relations of coming to take pharmaceutical medications that transcend the conceptual and relational terrain of rational decision-making perspectives. First, it explores disjunctures between the everyday healthwork of poor, socially marginalized PHAs and the terms of biomedical decision making. Second, it investigates the knowledge-mediating activities of community-based organizations that help mitigate those disjunctures.

Cure or control: complying with biomedical regime of diabetes in Cameroon

BACKGROUND

The objective of the study was to explore the cultural aspect of compliance, its underlying principles and how these cultural aspects can be used to improve patient centred care for diabetes in Cameroon.

METHODS

We used participant observation to collect data from a rural and an urban health district of Cameroon from June 2001 to June 2003. Patients were studied in their natural settings through daily interactions with them. The analysis was inductive and a continuous process from the early stages of fieldwork.

RESULTS

The ethnography revealed a lack of basic knowledge about diabetes and diabetes risk factors amongst people with diabetes. The issue of compliance was identified as one of the main themes in the process of treating diabetes. Compliance emerged as part of the discourse of healthcare providers in clinics and filtered into the daily discourses of people with diabetes. The clinical encounters offered treatment packages that were socially inappropriate therefore rejected or modified for most of the time by people with diabetes. Compliance to biomedical therapy suffered a setback for four main reasons: dealing with competing regimes of treatment; coming to terms with biomedical treatment of diabetes; the cost of biomedical therapy; and the impact of AIDS on accepting weight loss as a lifestyle measure in prescription packages. People with diabetes had fears about and negative opinions of accepting certain prescriptions that they thought could interfere with their accustomed social image especially that which had to do with bridging their relationship with ancestors and losing weight in the era of HIV/AIDS.

CONCLUSION

The cultural pressures on patients are responsible for patients' partial acceptance of and adherence to prescriptions. Understanding the self-image of patients and their background cultures are vital ingredients to improve diabetes care in low-income countries of Sub-Sahara Africa like Cameroon.

Chemotherapy as language: sound symbolism in cancer medication names

The concept of sound symbolism proposes that even the tiniest sounds comprising a word may suggest the qualities of the object which that word represents. Cancer-related medication names, which are likely to be charged with emotional meaning for patients, might be expected to contain such sound-symbolic associations. We analyzed the sounds in the names of 60 frequently-used cancer-related medications, focusing on the medications' trade names as well as the names (trade or generic) commonly used in the clinic. We assessed the frequency of common voiced consonants (/b/, /d/, /g/, /v/, /z/; thought to be associated with slowness and heaviness) and voiceless consonants (/p/, /t/, /k/, /f/, /s/; thought to be associated with fastness and lightness), and compared them to what would be expected in standard American English using a reference dataset. A Fisher's exact test for independence showed the chemotherapy consonantal frequencies to be significantly different from standard English (p=0.009 for trade; p<0.001 for "common usage"). For the trade names, the majority of the voiceless consonants were significantly increased compared to standard English; this effect was more pronounced with the "common usage" names (for the group, O/E=1.62; 95% CI [1.37, 1.89]). Hormonal and targeted therapy trade names showed the greatest frequency of voiceless consonants (for the group, O/E=1.76; 95% CI [1.20, 2.49]). Our results suggest that taken together, the names of chemotherapy medications contain an increased frequency of certain sounds associated with lightness, smallness and fastness. This finding raises important questions about the possible role of the names of medications in the experiences of cancer patients and providers.

Patient adherence to tuberculosis treatment: a systematic review of qualitative research

BACKGROUND

Tuberculosis (TB) is a major contributor to the global burden of disease and has received considerable attention in recent years, particularly in low- and middle-income countries where it is closely associated with HIV/AIDS. Poor adherence to treatment is common despite various interventions aimed at improving treatment completion. Lack of a comprehensive and holistic understanding of barriers to and facilitators of, treatment adherence is currently a major obstacle to finding effective solutions. The aim of this systematic review of qualitative studies was to understand the factors considered important by patients, caregivers and health care providers in contributing to TB medication adherence.

METHODS AND FINDINGS

We searched 19 electronic databases (1966-February 2005) for qualitative studies on patients', caregivers', or health care providers' perceptions of adherence to preventive or curative TB treatment with the free text terms "Tuberculosis AND (adherence OR compliance OR concordance)". We supplemented our search with citation searches and by consulting experts. For included studies, study quality was assessed using a predetermined checklist and data were extracted independently onto a standard form. We then followed Noblit and Hare's method of meta-ethnography to synthesize the findings, using both reciprocal translation and line-of-argument synthesis. We screened 7,814 citations and selected 44 articles that met the prespecified inclusion criteria. The synthesis offers an overview of qualitative evidence derived from these multiple international studies. We identified eight major themes across the studies: organisation of treatment and care; interpretations of illness and wellness; the financial burden of treatment; knowledge, attitudes, and beliefs about treatment; law and immigration; personal characteristics and adherence behaviour; side effects; and family, community, and household support. Our interpretation of the themes across all studies produced a line-of-argument synthesis describing how four major factors interact to affect adherence to TB treatment: structural factors, including poverty and gender discrimination; the social context; health service factors; and personal factors. The findings of this study are limited by the quality and foci of the included studies.

CONCLUSIONS

Adherence to the long course of TB treatment is a complex, dynamic phenomenon with a wide range of factors impacting on treatment-taking behaviour. Patients' adherence to their medication regimens was influenced by the interaction of a number of these factors. The findings of our review could help inform the development of patient-centred interventions and of interventions to address structural barriers to treatment adherence.

Ethnographic study of factors influencing compliance to intermittent preventive treatment of malaria during pregnancy among Yao women in rural Malawi

In Africa today one of the main strategies to reduce malaria infection during pregnancy is the promotion of intermittent preventive treatment (IPT). To date only a few studies have investigated the factors affecting compliance to IPT. This medical anthropology study aims to describe these factors from the perspective of pregnant women in rural Malawi. We examine women's knowledge and perceptions about the use of medication in pregnancy and the timing and motivation concerning use of antenatal clinic (ANC) services. In addition, the circumstances and interaction at the ANC and the IPT implementation process are described. The data were collected by applying an ethnographic approach, including focus group discussions (n=8), in-depth interviews (n=34), drug identification exercises, participant observation and a 'knowledge, attitudes and practices' survey (n=248). This study discovered several factors affecting IPT. These were: unclear messages about IPT with sulfadoxine-pyrimethamine (SP) from nurses; timing of SP-1; periodic shortages of SP; women's limited understanding of IPT-SP; tendency for late enrolment; and nurses' underperformance. The results of this study show that understanding of the multiple contexts affecting malaria prevention is important, and that ethnographic research is useful for discovering and solving problems beyond the scope of many other research approaches.

Treatment adherence among primary care patients in a historically disadvantaged community in South Africa: a qualitative study

The present study examined the issue of treatment adherence among a sample of 23 rural South African patients living with either hypertension or diabetes, or both. The sample was asked to participate in qualitative interviews that asked about various aspects of their experience of their illness and treatment. The analysis of the data focused on the content of participants' concerns and difficulties with adhering to treatment recommendations. The themes that emerged from the study were participants' attribution of the origin of their illness, their subjective experience of their illness, their concerns about the consequences of poor adherence, financial problems and psychosocial support.

Influences on uptake of reproductive health services in Nsangi community of Uganda and their implications for cervical cancer screening

Background

Cervical cancer is the most common female cancer in Uganda. Over 80% of women diagnosed or referred with cervical cancer in Mulago national referral and teaching hospital have advanced disease. Plans are underway for systematic screening programmes based on visual inspection, as Pap smear screening is not feasible for this low resource country. Effectiveness of population screening programmes requires high uptake and for cervical cancer, minimal loss to follow up. Uganda has poor indicators of reproductive health (RH) services uptake; 10% postnatal care attendance, 23% contraceptive prevalence, and 38% skilled attendance at delivery. For antenatal attendance, attendance to one visit is 90%, but less than 50% for completion of care, i.e. three or more visits.

Methods

We conducted a qualitative study using eight focus group discussions with a total of 82 participants (16 men, 46 women and 20 health workers). We aimed to better understand factors that influence usage of available reproductive health care services and how they would relate to cervical cancer screening, as well as identify feasible interventions to improve cervical cancer screening uptake.

Results

Barriers identified after framework analysis included ignorance about cervical cancer, cultural constructs/beliefs about the illness, economic factors, domestic gender power relations, alternative authoritative sources of reproductive health knowledge, and unfriendly health care services. We discuss how these findings may inform future planned screening programmes in the Ugandan context.

Conclusion

Knowledge about cervical cancer among Ugandan women is very low. For an effective cervical cancer-screening programme, awareness about cervical cancer needs to be increased. Health planners need to note the power of the various authoritative sources of reproductive health knowledge such as paternal aunts (Sengas) and involve them in the awareness campaign. Cultural and economic issues dictate the perceived reluctance by men to participate in women's reproductive health issues; men in this community are, however, potential willing partners if appropriately informed. Health planners should address the loss of confidence in current health care units, as well as consider use of other cervical cancer screening delivery systems such as mobile clinics/camps.

Narratives about illness and medication: a neglected theme/new methodology within pharmacy practice research. Part II: medication narratives in practice

AIM

Part 2 of this paper aims to provide a methodological framework for the study of medication narratives, including a semi-structured interview guide and suggested method of analysis, in an attempt to aid the development of narrative scholarship within pharmacy practice research. Examples of medication narratives are provided to illustrate their diversity and usefulness.

METHODS

The framework is derived from the work of other researchers and adapted for our specific purpose. It comes from social psychology, narrative psychology, narrative anthropology, sociology and critical theory and fits within the social constructionist paradigm. The suggested methods of analysis could broadly be described as narrative analysis and discourse analysis. Examples of medication narratives are chosen from a variety of sources and brief interpretations are presented by way of illustration.

CONCLUSION

Narrative analysis, a neglected area of research in pharmacy practice, has the potential to provide new understanding about how people relate to their medicines, how pharmacists are engaged in producing narratives and the importance of narrative in the education of students. IMPACT OF THE ARTICLE: This article aims to have the following impact on pharmacy practice research: Innovative approach to researching and conceptualising the use of medicines. Introduction of a new theoretical perspective and methodology. Incorporation of social science research methods into pharmacy practice research. Development of narrative scholarship within pharmacy.

Managing patient adherence and quality of life in epilepsy

Patient adherence to medication continues to be a cause of concern within the medical profession. This review examines the various methods of quantifying the level of patient adherence, progress in predicting causes of non-adherence, and the implications for its management. Contributions from the medical, health belief, and psychosocial models are discussed in order to highlight how the concept of adherence has changed over time. The impact of epilepsy, seizures, and taking antiepileptic drugs (AEDs) on both adherence and quality of life are also explored. The volume and quality of previous research conducted has enabled a number of predictive factors to be identified, from which various strategies have been developed. While this review concentrates on potential strategies in managing treatment adherence within epilepsy, findings can equally be applied to other chronic conditions.

[Partnership between patients' associations and health professionals: the case of the general practitioner]

Public authorities have opted to promote the representation of patients and health system users within health institutions and regional decision-making bodies. This raises one important question: that of the links and mutual benefits between independent primary providers and users' associations. Patients' associations in the health field are not that well-known among doctors, who are in fact only minutely affected by their activities and hence not very aware of them. The improved management of care provision, however, may well give rise to a triangular relationship: patient's association--primary care provider--hospital. The relationship between primary care and associations may largely depend upon hospital-based and delivered medical care. The "independent sector" referred to by these associations often concerns paramedical health professionals rather than independent GPs.

Psychosocial factors influencing Mexican-American women's adherence with hemodialysis treatment

Patients frequently do not fully adhere to treatment regimens. Despite the fact that this issue has been extensively researched, patient nonadherence is still not well understood. Previous studies have tended to neglect the study of phenomenological perceptions and psychosocial influences on nonadherence behavior as well as issues unique to culturally diverse populations. This author used an interpretive approach to examine the cognitive and phenomenological dimensions of how Mexican-American women receiving dialysis treatment experience their illness (n = 26). Poverty, longer treatment history, immigrant status, perceived identity losses, and family dysfunction emerged as factors that influenced treatment nonadherence among this purposive sample. This article moves from results to implications for social work practice with this population.

Unilateral treatment exit: a failure of retention or a failure of treatment fit?

This article highlights perceived weaknesses in the current understanding of unilateral client exit from alcohol and other drug psychosocial treatment. It is argued that unilateral client exit is typically interpreted as a "failure of retention" when it could equally be interpreted as a "failure of treatment fit"; that is, the failure to deliver treatment optimally suited to actual client attendance. The results from an exploratory study conducted within a failure of treatment fit framework are presented. This study explored the possibility that short-term outpatient alcohol and other drug (AOD) treatment attendance may be an intentional service use strategy and that short-term attendees may exit AOD treatment as satisfied, successful, consumers. Standardized questionnaires were administered to clients (n = 109) starting a new treatment episode between June-August 2003 at admission and two-months post admission. Questionnaires explored the accuracy of client estimates of future appointment attendance, the reasons for short-term service exit, the satisfaction and outcome ratings of short-term clients, and the extent to which these compared with their longer-term peers. Findings suggest short-term treatment attendance is not an intentional service use strategy. However, despite attending fewer appointments than intended, most short-term participants reported significant levels of service satisfaction and problem improvement, and at a level comparable with their longer term peers. Problem-improvement was endorsed as the number one reason for short-term service exit. Implications for treatment delivery are discussed in light of these findings.

Life skill interventions with homeless youth, domestic violence victims and adults with mental illness

SUMMARY This paper presents three exploratory studies of life skills interventions (employment, money management or food/nutrition) with 73 homeless individuals from four shelters and supportive housing programs located in the urban Midwest for youth, victims of domestic violence and adults with mental illness. The Ansell Casey Life Skills Assessment was administered prior to the eight group and individual sessions. Quizzes and posttests indicated clinical change in all groups, with statistical significance in the domestic violence group. The intervention implementation, challenges encountered, and strategies developed for implementing shelter-based interventions are discussed. Recommendations for successfully providing collaborative university-shelter clinical interventions are provided.

Religious attitudes toward prescriptions, medicines, and doctors in France

Although the social sciences have studied the influence of social environment on individual behaviors regarding medication, very little research has been done on the variations that exist between patients in equivalent social contexts but with diverse religious backgrounds. This article presents the results of research on the correlation between patients' religious-cultural background (Catholic, Protestant, Jewish, or Muslim) and their behaviors regarding medication. It shows that the cultural origin as well as the collective history of the groups to which patients belong impacts their attitudes toward prescriptions, medicines, their own bodies, and doctors.

Medication practice and feminist thought: a theoretical and ethical response to adherence in HIV/AIDS

Accurate self-administration of antiretroviral medication therapy for HIV/AIDS is a significant clinical and ethical concern because of its implications for individual morbidity and mortality, the health of the public, and escalating healthcare costs. However, the traditional construction of patient medication adherence is oversimplified, myopic, and ethically problematic. Adherence relies on existing social power structures and western normative assumptions about the proper roles of patients and providers, and principally focuses on patient variables, obscuring the powerful socioeconomic and institutional influences on behaviour. Some professionals advocate for alternate approaches to adherence, but many of the available alternatives remain conceptually underdeveloped. Using HIV/AIDS as an exemplar, this paper presents medication practice as a theoretical reconstruction and explicates its conceptual and ethical evolution. We first propose that one of these alternatives, medication practice, broadens the understanding of individuals' medication-taking behaviour, speaks to the inherent power inequities in the patient-provider interaction, and addresses the ethical shortcomings in the traditional construal. We then integrate medication practice with feminist thought, further validating individuals' situated knowledge, choices, and multiple roles; more fully recognizing the individual as a multidiminsional, autonomous human being; and reducing notions of obedience and deference to authority. Blame is thus extricated from the healthcare relationship, reshaping the traditionally adversarial components of the interaction, and eliminating the view of adherence as a patient problem in need of patient-centred interventions.

GPs' perspectives of type 2 diabetes patients' adherence to treatment: A qualitative analysis of barriers and solutions

BACKGROUND

The problem of poor compliance/adherence to prescribed treatments is very complex. Health professionals are rarely being asked how they handle the patient's (poor) therapy compliance/adherence. In this study, we examine explicitly the physicians' expectations of their diabetes patients' compliance/adherence. The objectives of our study were: (1) to elicit problems physicians encounter with type 2 diabetes patients' adherence to treatment recommendations; (2) to search for solutions and (3) to discover escape mechanisms in case of frustration.

METHODS

In a descriptive qualitative study, we explored the thoughts and feelings of general practitioners (GPs) on patients' compliance/adherence. Forty interested GPs could be recruited for focus group participation. Five open ended questions were derived on the one hand from a similar qualitative study on compliance/adherence in patients living with type 2 diabetes and on the other hand from the results of a comprehensive review of recent literature on compliance/adherence. A well-trained diabetes nurse guided the GPs through the focus group sessions while an observer was attentive for non-verbal communication and interactions between participants. All focus groups were audio taped and transcribed for content analysis. Two researchers independently performed the initial coding. A first draft with results was sent to all participants for agreement on content and comprehensiveness.

RESULTS

General practitioners experience problems with the patient's deficient knowledge and the fact they minimize the consequences of having and living with diabetes. It appears that great confidence in modern medical science does not stimulate many changes in life style. Doctors tend to be frustrated because their patients do not achieve the common Evidence Based Medicine (EBM) objectives, i.e. on health behavior and metabolic control. Relevant solutions, derived from qualitative studies, for better compliance/adherence seem to be communication, tailored and shared care. GPs felt that a structured consultation and follow-up in a multidisciplinary team might help to increase compliance/adherence. It was recognized that the GP's efforts do not always meet the patients' health expectations. This initiates GPs' frustration and leads to a paternalistic attitude, which may induce anxiety in the patient. GPs often assume that the best methods to increase compliance/adherence are shocking the patients, putting pressure on them and threatening to refer them to hospital.

CONCLUSION

GPs identified a number of problems with compliance/adherence and suggested solutions to improve it. GPs need communication skills to cope with patients' expectations and evidence based goals in a tailored approach to diabetes care.

Medicine taking decisions: schizophrenia in comparison to asthma and epilepsy

This paper outlines a recent PhD study that explored factors underpinning decisions of people with schizophrenia regarding neuroleptic medicine taking. Relevant studies tend to be within the world view of psychiatry, resting on traditional concepts of compliance and insight. These studies examined schizophrenia outwith the context of other illnesses taking a snap shot view of medicine taking decision making, thus de-emphasizing its process. The chosen method of grounded theory (Glaser and Strauss 1967) overcomes these deficiencies. Stage 1 data arose from patient interviews, patients with asthma, epilepsy and schizophrenia contributed (n = 45), carers also sometimes contributed (n = 11), all three conditions being episodic disorders vulnerable to environmental stressors. Stage 2 develops from stage 1, mental health workers involved in the care of people with schizophrenia were interviewed, plus one asthma specialist and one epilepsy specialist (n = 16). Their views were compared to perspectives arising from the patient interviews and were included in the data, out of which an explanatory typology emerged. The three parts of the typology comprise the study's major categories and are labelled as: direct-reactive, deferential-compliant, and active discerning and optimizing. Active discerning and optimizing consists of two stages; experimental-reflective and consolidation. The core category of responsive resolution contains themes which run through all major categories.

Understanding treatment adherence in affective disorders: a qualitative study

The objective of this study was to explore the perspective of depressed patients, their family and mental health professionals from their community mental health centre (CMHC) on factors related to treatment adherence. We conducted eight separate focus groups involving patients, their families and their therapists from three CMHCs. A total of 52 persons were involved. The groups explored patients' and family's explanatory model of depression, perceptions about the course of the disease, the role of medication and other treatments, the main causes of non-adherence, and interventions which would help increase it. Patients and families had a complex cognitive model of depression, which combined intrinsic vulnerability, psychological suffering during childhood and adolescence, and adverse life events. Drugs as well as other treatments were considered helpful, more so by patients than by family members. Denial of the disease and need to test its continuing presence were the main causes of non-adherence for patients, while adverse reactions did not play a relevant role. Mental health professionals tended to underestimate non-adherence in depressed patients, and did not question their patients about medication adherence. Family members needed more information on depression, on how to manage their relatives, as well as psychological and social support for themselves. The study allowed for the identification of a number of specific interventions aimed at facilitating treatment adherence, such as providing more information to patients and families, and training doctors and nurses in effective prevention and management of non-adherence.

Drug compliance and identity: reasons for non-compliance. Experiences of medication from persons with asthma/allergy

The aim of the study was to describe patient experiences of medication. Patients with asthma/allergy were interviewed in depth twice with 8 years between. The interviews were analysed according to the phenomenographic approach and three categories, one with four sub-categories, were identified: 'access to medicine is important to relieve discomfort and to avoid fear', 'medicine damages your body and your identity without curing the illness' (because 'you can become immune or addicted', 'the ability of your body to heal itself is weakened', 'your body's own signals are camouflaged' and 'you become stigmatised') and 'production and distribution of medicine is a profit-seeking commercial undertaking which is not primarily aimed at curing the patient'. Medication experiences were stable over time. Sociological and biological survival must be compared in an open discussion along with the patient's and health professional's different reasons for how they take or prescribe medication.

Measurement, Correlates, and Health Outcomes of Medication Adherence Among Seniors

OBJECTIVE

To provide a comprehensive review of the literature on the measurement, correlates, and health outcomes of medication adherence among community-dwelling older adults.

DATA SOURCES

Searches of MEDLINE, PubMed, and International Pharmaceutical Abstracts databases for English-language literature (1966–December 2002) were conducted using one or more of the following terms: elderly, adherence/nonadherence, compliance/noncompliance, medication/drug, methodology/measurement, and hospitalization.

STUDY SELECTION AND DATA EXTRACTION

From the above search, studies of medication adherence in community-dwelling seniors were selected for review along with relevant publications from the reference lists of articles identified in the initial database search.

DATA SYNTHESIS

Although several methods are available for the assessment of adherence, accurate measurement continues to be difficult. The available evidence suggests that polypharmacy and poor patient–healthcare provider relationships (including the use of multiple providers) may be major determinants of nonadherence among older persons, with the impact of most sociodemographic factors being negligible. There is little consensus regarding other determinants of nonadherence. Relatively few high-quality investigations have examined the associations between nonadherence and subsequent health outcomes. Available data provide some support for increased health risks with nonadherence. However, interventions to improve adherence have seldom demonstrated positive effects on health outcomes.

CONCLUSIONS

There are few empirical data to support a simple systematic descriptor of the nonadherent patient. The inconsistencies across studies may be attributable, in part, to the inherent difficulties involved in the measurement of a behavioral risk factor such as nonadherence. Future research in this area would be strengthened by incorporation of detailed assessments of patient-reported reasons for nonadherence, the appropriateness of drug regimens, and the effect of nonadherence on health outcomes.

From compliance to concordance: barriers to accomplishing a re-framed model of health care interactions

As a framework for organising health care interactions, compliance and adherence have come in for increasing criticism in recent years. It has been suggested that interactions with patients should not be viewed simply as opportunities to reinforce instructions around treatment: rather, they should be seen as a space where the expertise of patients and health professionals can be pooled to arrive at mutually agreed goals. This concept-known as concordance-is attracting increasing interest in health services research within the UK. In this paper, we seek to empirically explore the relevance of a re-framed consultation through qualitative interviews with a small group of English speaking patients of Pakistani origin with a diagnosis of type 2 diabetes. We suggest that the focus of many respondents in this study on material and structural factors limiting diabetic regimen integration and the emphasis on a 'doctor-centred' model of health care interactions represent distinct problems for the accomplishment of the concordance project. However, given that some patients sought greater understanding and appreciation by health professionals of the subjective aspects of living with diabetes, if it is evaluated at the level of health care relationships, rather than health outcomes (such as improved compliance) concordance may well be a significant development for those who suggest that respect for the patients agenda is a fundamental aspect of health care.

A study of factors facilitating and inhibiting the willingness of the institutionalized disabled elderly for rehabilitation: a United States-Japanese comparison

The high prevalence of 'bedridden elderly' in Japan is at least three times higher than that of any other industrialized country. To decrease likelihood of being bedridden, it is important to cultivate and maintain the willingness of older disabled patients for rehabilitation, and to preserve functioning in activities of daily living (ADL). The purpose of this study was to identify the factors facilitating and inhibiting the willingness of institutionalized disabled older adults for rehabilitation with respect to physical, goal-attainment, psychological and cultural aspects. The convenience sample consisted of 71 disabled older adults (45 in Japan and 26 in the USA). 46 subjects (64.8%) were identified as 'willing for rehabilitation', whereas 25 (35.2%) were 'unwilling for rehabilitation'. The data were gathered using structured interviews to subjects and administering questionnaires to the nurses. The data were compared between the 'willing' and the 'unwilling', and between those from Japan and from the USA by cross-tabular and correlational analyses. The major findings in this study were as follows: (1) Factors found to facilitate willingness of older persons for rehabilitation included: high independence level in ADL, generalized endurance/stamina, lack of pain, mutual goal agreement between old people and care staff, and no presence of regressive behavior. (2) Factors found to inhibit willingness of older persons for rehabilitation included: lower independence in ADL, presence of pain, generalized little stamina, depression, presence of regressive behavior, and dementia, and expectation of another person's help all the time. Healthcare workers need to be aware of patients who are subject to factors inhibiting willingness, and to promote factors facilitating willingness, in order to prevent the elderly with disabilities from becoming bedridden. In addition, the implications of this study are for a multidimensional functional assessment to be part of the rehabilitation intake in order to better understand each individual and motivate his/her optimum level of functional ability.

Nurses and 'difficult' patients: negotiating non-compliance

BACKGROUND

There is a large body of nursing literature on patient non-compliance. While some articles address non-compliance as a patient problem to be resolved by nursing interventions, there is also a growing number that critique this approach. This reflects the discomfort many nurses feel about the practice of labelling patients as non-compliant.

AIM

The aim of this discussion paper is to build on the critical nursing literature to offer an alternative to the interventions commonly directed at patients who do not follow health care advice. This alternative approach locates patients within their social context and focuses on those who adapt health care advice to fit with their beliefs, life situation and circumstances. The aim is to encourage nurses to learn about how health care treatments affect patients'lives, and not merely their health.

METHOD

Specific nursing articles were reviewed to demonstrate the ways in which the concept of compliance is used within the nursing literature. These articles were then used to support an argument that promotes a patient-centred approach to health care.

CONCLUSION

A patient-centred approach involves transferring power and authority away from health care professionals and towards patients. We encourage nurses to take a leadership role by changing the way in which health care is delivered towards a focus on patients'lives. Learning about patients' lives may assist nurses to offer health information to patients that is more relevant and, therefore, useful.

How and by whom care is delivered influences anti-inflammatory use in asthma: Results of a national population survey

BACKGROUND

Studies examining the influence of provider behavior and patterns of care delivery on the use of anti-inflammatory asthma therapy have been limited to selected populations or have been unable to assess the appropriateness of therapy for individuals. We have previously reported the influence of sociodemographic variables and asthma severity on reported use of asthma medications in the United States.

OBJECTIVE

We sought to examine the influence of patterns of care delivery and clinician behavioral factors on the use of anti-inflammatory medication by patients with asthma.

METHODS

We performed a cross-sectional national random digit dial household telephone survey in 1998 of adult patients and parents of children with current asthma. Respondents were classified as having current asthma if they had a physician's diagnosis of asthma and were either taking medication for asthma or had asthma symptoms during the past year.

RESULTS

One or more persons met the study criteria for current asthma in 3273 (7.8%) households in which a screening questionnaire was completed. Of the 2509 persons (721 children <16 years of age) with current asthma interviewed, 507 (20.1%) reported current use of anti-inflammatory medication. In a multiple logistic regression model controlling for asthma symptoms, reported anti-inflammatory use was significantly associated with patients reporting their physician having an excellent ability to explain asthma management (odds ratio [OR], 1.47; 95% CI, 1.09-1.98), scheduling regular visits to a physician for asthma (OR, 1.30; 95% CI, 1.02-1.64), having a written asthma action plan (OR, 1.63; 95% CI, 1.29-2.06), and being of white, non-Hispanic ethnicity (OR, 1.53; 95% CI, 1.19-1.98), along with markers of greater asthma morbidity, missing 6 or more days from work or school in the past year (OR, 1.29; 95% CI, 1.01-1.65), and hospitalization for asthma in the past year (OR, 1.74; 95% CI, 1.19-2.53). Anti-inflammatory use was less likely to be reported with younger age (OR, 0.82; 95% CI, 0.73-0.94), lower long-term asthma symptom burden (OR, 0.82; 95% CI, 0.71-0.94), use of 4 or fewer reliever inhaler canisters in the past year (OR, 0.50; 95% CI, 0.43-0.58), and smoking (OR, 0.50; 95% CI, 0.37-0.68).

CONCLUSION

How asthma care is delivered influences the use of anti-inflammatory medication. Strategies to increase regular evaluation by a physician interested in asthma, particularly for minority patients, and to increase a physician's ability to communicate asthma management to patients might improve use of anti-inflammatory therapy among patients with asthma.

Medication-taking beliefs of adult renal transplant recipients

PURPOSE

To describe the medication-taking beliefs of younger and older adult renal transplant recipients.

METHOD

A descriptive design was used to study 16 adult renal transplant recipients, 8 older and 8 younger, recruited from a renal transplant program in the midwest. A semistructured interview was conducted based on the theory of planned behavior. Data were examined using manifest content analyses.

RESULTS

Both groups had similar behavioral, normative, control, and problem-solving medication-taking beliefs. Planning ahead, organizing, using cues, involving a support person, and remembering the donor and life on dialysis were key control beliefs. Differences were found in beliefs regarding difficulties with taking immunosuppressive medications. The majority in both groups mentioned forgetting to take their immunosuppressive medications on at least one occasion. CONCLUSIONS/APPLICATION: As empiric evidence in this area grows, the clinical nurse specialist is paramount in assisting both younger and older renal transplant recipients with immunosuppressive medication taking and, consequently, in fostering better outcomes.

Development and validation of a survey to assess barriers to drug use in patients with chronic heart failure

Scot H. Simpson, Pharm.D., M.Sc., Jeffrey A. Johnson, Ph.D., Karen B. Farris, Ph.D., and Ross T. Tsuyuki, Pharm.D., M.Sc. Objective. To report the development of and initial experience with a survey designed to assess patient-perceived barriers to drug use in ambulatory patients with heart failure. Methods. The Barriers to Medication Use (BMU) survey, developed from previous qualitative work by our group, was administered to 128 consecutive patients attending an outpatient heart failure clinic. The first 42 patients to return the survey were mailed a second survey to evaluate response stability over time. The survey contained 31 questions in five barrier domains (knowledge, previous drug therapy experiences, social support, communication, and relationship with health care professionals). Patients also completed the Minnesota Living with Heart Failure (MLHF) questionnaire and a self-reported drug use scale. Frequency of drug refills was used to estimate adherence. Reliability and construct validity of the BMU survey were assessed using correlation coefficients. Results. Response rates were 89% and 93% for the first and retest surveys, respectively The BMU survey showed modest internal consistency in the overall survey and in two of the five barrier domains. Responses to the first and retest surveys showed good stability over time in the overall survey and in four of the five barrier domains. Patients with good adherence reported few barriers; however, the association was not strong (Pearson correlation coefficient r = -0.14, p=0.14). Patients who reported few barriers also reported better MLHF scores (r = 0.42, p < 0.001), with the strongest association in the social support domain (r = 0.53; p < 0.001). All respondents reported having a good relationship with health care professionals. The most common barriers to drug use were poor support networks and previous adverse reactions. Conclusion. The BMU survey demonstrated reasonable reliability and validity characteristics in this first clinical experience. Despite high adherence, patients still reported barriers that may hinder optimal drug use.

Task orientated nursing in a tuberculosis control programme in South Africa: where does it come from and what keeps it going?

Task oriented nursing is associated with traditional hospital ward organisational practice. This paper describes task orientation in a tuberculosis control programme which forms part of the public health system in Cape Town, South Africa. Task oriented practice is illustrated with clinical data from a focused ethnography on the work of nurses in a tuberculosis control programme. The origins of task orientation are traced to the colonial history of nursing in South Africa. The authors explore both the explicit and more functional reasons for maintaining task orientation, as well as the implicit and mostly unconscious socially structured defences which contribute to the continuation of this form of practice. Unless attention is given to the complexities of this phenomenon, initiatives to change task oriented practice may continue to fail.

The health behaviours of Chinese people with chronic illness

This study was undertaken to elucidate the type and range of health-promoting behaviours that Chinese people with chronic illness perform to enhance their health. Eight people with a diagnosed chronic illness were interviewed using a semi-structured interview schedule. From the perspectives of these subjects, health behaviour comprises three dimensions: physical, psychosocial and spiritual. The results of this study clarify health behaviours amongst Chinese people with a chronic illness and illustrate the important influence that culture has upon such activity. Additionally, exploring the health behaviours of these Chinese people can be used to inform and enable nurses to adjust their practices to relate more appropriately to patients' perspectives.