Compliance

A conceptual framework and exploratory model for health and social intervention acceptability among African adolescents and youth

Intervention acceptability has become an increasingly key consideration in the development, evaluation and implementation of health and social interventions. However, to date this area of investigation has been constrained by the absence of a consistent definition of acceptability, comprehensive conceptual frameworks disaggregating its components, and few reliable assessment measures. This paper aims to contribute to this gap, by proposing a conceptual framework and exploratory model for acceptability with a specific priority population for health and developmental interventions: adolescents and youth in Africa. We document our multi-staged approach to model development, comprising both inductive and deductive components, and both systematic and interpretative review methods. This included thematic analyses of respective acceptability definitions and findings, from 55 studies assessing acceptability of 60 interventions conducted with young people aged 10-24 in (mainly Southern and Eastern) Africa over a decade; a consideration of these findings in relation to Sekhon et al.'s Theoretical Framework of Acceptability (TFA); a cross-disciplinary review of acceptability definitions and models; a review of key health behavioural change models; and expert consultation with interdisciplinary researchers. Our proposed framework incorporates nine component constructs: affective attitude, intervention understanding, perceived positive effects, relevance, perceived social acceptability, burden, ethicality, perceived negative effects and self-efficacy. We discuss the rationale for the inclusion and definition of each component, highlighting key behavioural models that adopt similar constructs. We then extend this framework to develop an exploratory model for acceptability with young people, that links the framework components to each other and to intervention engagement. Acceptability is represented as an emergent property of a complex, adaptive system of interacting components, which can influence user engagement directly and indirectly, and in turn be influenced by user engagement. We discuss opportunities for applying and further refining or developing these models, and their value as a point of reference for the development of acceptability assessment tools.

Lack of Harmonized Adherence Criteria in Allergen Immunotherapy Prevents Comparison of Dosing and Application Strategies: A Scoping Review

Allergen immunotherapy (AIT) involves the application of increasing doses of allergen extract (as oral, sublingual, or subcutaneous immunotherapy) until immunologic tolerance is reached. Successful AIT relies on the consistent administration of allergen extract; therefore, adherence to these treatments is vital for compelling long-term results. Our review discusses the current terminology from adherence research in general, summarizes 25 current studies on adherence research in AIT in a scoping literature review, and delineates recommendations for tools and parameters for adherence research, aiming to improve outcomes in AIT. Almost every adherence study in AIT published to date used different tools, parameters, and data sources for measuring adherence and persistence rates. Unfortunately, an easily accessible, objective parameter or biomarker for monitoring treatment adherence and success has not yet been established for AIT. This situation calls for the development of an international core outcomes set for AIT that defines what is exactly meant by AIT adherence and how AIT adherence should be consistently measured. Therefore, we exemplarily present results and conclusions from adherence research in chronic diseases other than allergology. We aim to facilitate the development of advanced methods, considering the challenging disease specificities of these parameters in a routine care setting of AIT.

Precautionary Measures and Illness Attitudes toward COVID-19 among a Sample of the Kuwaiti Population

Since the World Health Organization (WHO) declared COVID-19 a global pandemic, several strict measures have been recommended to prevent and control the spread of the virus worldwide. This study aims to examine the associations between precautionary health behaviors (eating vitamins, washing hands continuously, eating healthy food, putting on masks, wearing gloves, and maintaining a safe distance) and illness attitudes (worry about illness, concern about pain, hypochondriacal beliefs, thanatophobia, and treatment experience). An online questionnaire was distributed to 1,413 Kuwaiti participants using the convenience-sampling method via the WhatsApp application. The online survey collected data based on the Illness Attitude toward COVID-19 Scale (IATCS) and on demographics. The findings of the study show that there are significant associations between the illness attitudes of participants and the precautionary health behaviors they adopted during the COVID-19 pandemic in Kuwait. Illness attitudes toward COVID-19 significantly affect the health behaviors of individuals. The health behaviors become precautionary measures aimed at preventing infection from COVID-19.

Precarious hope and reframing risk behavior from the ground up: insight from ethnographic research with Rwandan urban refugees in Yaoundé, Cameroon

BACKGROUND

Theoretical and methodological research on risk-taking practices often frames risk as an individual choice. While risk does occur at individual level, it is determined by aspirations which are connected to others and society. For many displaced women globally, these aspirations are often linked to the well-being of their children and other household members. This article explores the links between aspirations for the future, gendered household dynamics, and health risk-taking behavior among the Rwandan urban refugee community.

METHODS

This analysis drew from participant observation, focus group discussions, and in-depth interviews with 49 male and 42 female household members from 36 Rwandan refugee households in Yaoundé, Cameroon. The fieldwork was conducted over 12 months between May-August 2016, May-August 2017, and February-August 2018.

RESULTS

We observed that while there was considerable convergence among household members in aspirations, there was considerable difference in risk-taking practices engaged to achieve them with women often assuming the greatest risks. These gendered realities of risk were not only related to structural concerns including access to different forms of capital, but also to socio-cultural gendered expectations of women, how risks were defined and justified, and household dynamics that drove the gendered reality of observed risk-behavior.

CONCLUSIONS

Humanitarian programs and policies are distinctly finite in nature; focused on the short-term needs of persons affected by conflict. However, many humanitarian situations in the world are protracted. In the midst of these challenges, themes of future-orientation, possibilities, and shared aspirations for a better future emerge. These aspirations and the practices, including risk-taking practices that stem from them are central to understand if we are to ensure a just peace and stability in displaced communities throughout the developing world. Our analysis highlights the need to examine sociocultural dimensions related to hopes for the future, gender, and household dynamics as a way to understand risk behavior. We propose this can be done through a framework of precarious hope which we put forward in this paper, in which hope, agency, sociocultural and political economic contexts situate risk as a gendered practice of hope amidst constraint.

Using the transtheoretical model's stages of change to predict medication adherence in patients with type 2 diabetes mellitus in a primary health care setting

BACKGROUND

Qatar is currently experiencing a worrying increase in the prevalence of diabetes mellitus (DM). One of the most common reasons for uncontrolled DM is non-adherence to medications. The socio-behavioral intervention has proven effective in some chronic illnesses.

OBJECTIVES

To assess the stages of change (SOC) and medication adherence scores of type 2 diabetes mellitus (T2DM) patients visiting primary healthcare institutions in Qatar, and to evaluate the cause and effect relationship between SOC and adherence to antidiabetic medications.

METHODS

The 8-item Morisky Medication Adherence Scale (MMAS-8) was used to assess medication adherence, and a 2-item SOC questionnaire was utilized to classify the SOC. The analysis to determine if the SOC could predict medication adherence while controlling for demographic characteristics, total number of prescribed medications and disease duration was done using hierarchical multiple regression.

RESULTS

The final analysis included 387 patients. In relation to medication adherence, majority of the patients were in the maintenance stage (76.7%), followed by the preparation stage (14.7%), the action stage (3.9%), the contemplation stage (3.4%) and the precontemplation stage (1.3%). Most of the patients were in high adherence towards antidiabetic medications (50.3%) followed by low level (26.4%) and medium level (23.3%). SOC was significant and positively predicted medication adherence, which accounted for around 58 to 60% (p < 0.001) while controlling for covariates.

CONCLUSIONS

SOC was significant and positively predicted medication adherence. The study recommends that the SOC questionnaire could potentially be used to identify patients at risk for low adherence.

Construction of an adherence rating scale for exercise therapy for patients with knee osteoarthritis

Background

Knee osteoarthritis (KOA) is one of the most common chronic diseases in the elderly and is the primary cause of the loss of motor function and disability in this population. Exercise therapy is a core, basic and matureand treatment method of treating patients with KOA. Exercise therapy is “strongly recommended” or “recommended” in the diagnosis and treatment guidelines of osteoarthritis in many countries, and most scholars advocate exercise therapy as the preferred rehabilitation method for KOA patients. However, poor long-term adherence is a serious problem affecting the therapeutic effect of this mature treatment. The objective of this study was to construct a concise and practical adherence rating scale (ARS) based on the exercise therapy adherence prediction model in patients with knee osteoarthritis.

Methods

A binary logistic regression model was established, with the adherence of 218 cases of KOA patients as the dependent variable. The patients’ general information, exercise habits, knowledge, attitude, and exercise therapy were independent variables. The regression coefficients were assigned to various variables in the model, and the ARS was constructed accordingly. Receiver operating characteristic curves and curve fitting were used to analyse the effect of the ARS in predicting the adherence and to determine the goodness of fit for the adherence. The external validity of the ARS was examined in a randomized controlled trial.

Results

The construction of the adherence model and the ARS included the following variables: age (1 point), education level (1 point), degree of social support (2 points), exercise habits (3 points), knowledge of KOA prevention and treatment (2 points), degree of care needed to treat the disease (1 point), familiarity with exercise therapy (4 points) and treatment confidence (3 points). The critical value of the total score of the ARS was 6.50, with a sensitivity of 87.20% and a specificity of 76.34%.

Conclusions

A KOA exercise therapy adherence model and a simple and practical ARS were constructed. The ARS has good internal validity and external validity and can be used to evaluate the adherence to exercise therapy in patients with KOA.

Making a reality of user involvement in community mental health services

User centred services as an ideology have not become a reality of everyday clinical practice. In this paper we introduce a series of articles which describe user centred practice in a south London community-based rehabilitation service for the severely mentally ill. We emphasise the medical consultation style adopted, the service management style and specific initiatives allowing users to influence our practice and shape functional and structural components of the service.

Assessment of Determinants of Compliance to Twelve Health Behaviors: Psychometric Evaluation of the Health Behavior Schedule II

The test-retest reliability and content and construct validity of the Health Behavior Schedule II were examined. The Health Behavior Schedule II is a self-report intended to assess 45 potential predictors of compliance for 12 mainstream health practices: (1) eating a healthy diet, (2) exercising regularly, (3) flossing teeth daily, (4) protecting skin from sun, (5) wearing a seat belt, (6) practicing safe sex, (7) wearing a bike safety helmet, (8) not smoking cigarettes, (9) limiting alcohol consumption, (10) taking medication as prescribed, (11) obtaining cervical cancer screen, and (12) breast self-examination. The predictor items of the Health Behavior Schedule II were rationally derived from the Health Compliance Model-II and independently evaluated by three expert judges for content validity. The psychometric status of the Schedule was assessed using a multiethnic sample of 461 college students. 12 stepwise multiple regression analyses yielded 24 items as significant predictors of compliance. The configuration of predictor items varied across the 12 health behaviors with self-efficacy as the only common predictor. Effect size estimates were greatest for cervical cancer screening ( R2 = .65) and least for breast self-exams ( R2 = .38). Each predictor has implications for compliance enhancement strategies. These findings provide preliminary support for the utility of the questionnaire in assessing potential improvements in health compliance outcomes among young adults.

Predicting adherence to antiretroviral therapy among pregnant women in Guyana: Utility of the Health Belief Model

Barriers to antiretroviral therapy (ART) adherence among pregnant women are varied and complex. This study explored the constructs of a theoretical model, the Health Belief Model (HBM) to understand and predict ART adherence among pregnant women in Guyana. A cross-sectional study surveyed 108 pregnant women attending 11 primary care clinics. ART adherence ranging from the past weekend to three months was assessed through self-reports, and health beliefs with the Adherence Determinants Questionnaire (ADQ). Constructs with sufficient variation in responses were tested for association with the level of adherence using Spearman's rank correlation coefficient and test. Sixty-seven per cent (72) of the women reported being always adherent. Although there was positive endorsement of ART treatment and adherence, the HBM did not help in understanding or predicting ART adherence in this population. Only one item from the perceived susceptibility construct was significantly associated (p = 0.009) with adherence. Interventions are warranted to address ART adherence in this population, as 19% of the women were recently non-adherent. Although the ADQ did not contribute to a deeper understanding or provide insight into pathways that can be targeted for intervention, theoretical models can play a key role in identifying these pathways.

Patient Preferences for Receiving Education on Venous Thromboembolism Prevention - A Survey of Stakeholder Organizations

Importance

Venous thromboembolism (VTE) is a major cause of morbidity and mortality among hospitalized patients and is largely preventable. Strategies to decrease the burden of VTE have focused on improving clinicians’ prescribing of prophylaxis with relatively less emphasis on patient education.

Objective

To develop a patient-centered approach to education of patients and their families on VTE: including importance, risk factors, and benefit/harm of VTE prophylaxis in hospital settings.

Design, Setting and Participants

The objective of this study was to develop a patient-centered approach to education of patients and their families on VTE: including importance, risk factors, and benefit/harm of VTE prophylaxis in hospital settings. We implemented a three-phase, web-based survey (SurveyMonkey) between March 2014 and September 2014 and analyzed survey data using descriptive statistics. Four hundred twenty one members of several national stakeholder organizations and a single local patient and family advisory board were invited to participate via email. We assessed participants’ preferences for VTE education topics and methods of delivery.

Participants wanted to learn about VTE symptoms, risk factors, prevention, and complications in a context that emphasized harm. Although participants were willing to learn using a variety of methods, most preferred to receive education in the context of a doctor-patient encounter. The next most common preferences were for video and paper educational materials.

Conclusions

Patients want to learn about the harm associated with VTE through a variety of methods. Efforts to improve VTE prophylaxis and decrease preventable harm from VTE should target the entire continuum of care and a variety of stakeholders including patients and their families.

Effect of mobile telephone reminders on treatment outcome in HIV: evidence from a randomised controlled trial in India

OBJECTIVE

To assess whether customised mobile phone reminders would improve adherence to therapy and thus decrease virological failure among HIV infected patients starting antiretroviral treatment (ART).

DESIGN

Randomised controlled trial among HIV infected patients initiating antiretroviral treatment.

SETTING

Three diverse healthcare delivery settings in south India: two ambulatory clinics within the Indian national programme and one private HIV healthcare clinic.

PARTICIPANTS

631 HIV infected, ART naïve, adult patients eligible to initiate first line ART were randomly assigned to mobile phone intervention (n=315) or standard care (n=316) and followed for 96 weeks..

INTERVENTION

The intervention consisted of customised, interactive, automated voice reminders, and a pictorial message that were sent weekly to the patients' mobile phones for the duration of the study.

MAIN OUTCOME MEASURES

The primary outcome was time to virological failure (viral load >400 copies/mL on two consecutive measurements). Secondary outcomes included ART adherence measured by pill count, death rate, and attrition rate. Suboptimal adherence was defined as mean adherence <95%.

RESULTS

Using an intention-to-treat approach we found no observed difference in time to virological failure between the allocation groups: failures in the intervention and standard care arms were 49/315 (15.6%) and 49/316 (15.5%) respectively (unadjusted hazard ratio 0.98, 95% confidence interval 0.67 to 1.47, P=0.95). The rate of virological failure in the intervention and standard care groups were 10.52 and 10.73 per 100 person years respectively. Comparison of suboptimal adherence was similar between both groups (unadjusted incidence rate ratio 1.24, 95% CI 0.93 to 1.65, P=0.14). Incidence proportion of patients with suboptimal adherence was 81/300 (27.0%) in the intervention arm and 65/299 (21.7%) in the standard care arm. The results of analyses adjusted for potential confounders were similar, indicating no significant difference between the allocation groups. Other secondary outcomes such as death and attrition rates, and subgroup analysis also showed comparable results across allocation groups.

CONCLUSIONS

In this multicentre randomised controlled trial among ART naïve patients initiating first line ART within the Indian national programme, we found no significant effect of the mobile phone intervention on either time to virological failure or ART adherence at the end of two years of therapy.Trial registration Current Controlled Trials ISRCTN79261738.

A new taxonomy for describing and defining adherence to medications

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines ('Adherence to medications', 'Management of adherence') and the discipline that studies those processes ('Adherence-related sciences'). 'Adherence to medications' is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

A new taxonomy for describing and defining adherence to medications

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines ('Adherence to medications', 'Management of adherence') and the discipline that studies those processes ('Adherence-related sciences'). 'Adherence to medications' is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

Compliance Therapy: An Intervention Targeting Insight and Treatment Adherence in Psychotic Patients

A randomized controlled trial of a new intervention based on motivational interviewing and cognitive approaches to psychosis (Compliance Therapy) has shown improvements in insight, attitudes to medication and compliance in an unselected sample of consecutively admitted patients with acute psychotic disorders. In the introduction, previous research focusing on cognitive interventions in psychosis and systematically tested psychoeducational approaches to compliance are reviewed. The content of our intervention is described with examples of the principal techniques used, together with a description of the progress of therapy in two individual cases. We conclude that the intervention is eminently applicable in the typical clinical setting.

Non healing leg ulcers and the nurse-patient relationship. Part 2: the nurse's perspective

This paper focuses on the experiences of four community nursing teams responsible for the care of a small group of patients with leg ulcers who they had identified as 'non healing' and 'non concordant' with treatment. Four focus groups were held, one with each community nursing team, to examine the issues underpinning the labelling of these patients as 'non healing' and 'non concordant'. There was an expectation that patients should obey treatment instructions and be positive and participative and there was a strongly felt link between concordance and healing of the ulcer. However, limited non concordance was considered to be acceptable as long as the patient continued to progress. Nurses viewed ulcer healing as the priority even though this was unlikely and differed from the patient's priority of achieving comfort. Patient behaviour was an important determinant of labelling by nurses. Efforts by patients to exert some control over their own care were met with them being viewed as 'difficult', 'uncooperative' and 'non compliant'. There was also a pervasive level of stress, distress and anxiety among the community nurse participants, which led to distancing and blaming that undermined the nurse-patient relationship. At the centre of a successful nurse-patient relationship is a non judgemental partnership that can often be challenging to achieve especially when ulcers fail to heal.

Non healing leg ulcers and the nurse-patient relationship. Part 1: the patient's perspective

This paper reports on a study that explored the relationship between patients with non healing leg ulcers and the nurses providing their care in a community setting. Qualitative data were collected from five patients whose leg ulcers were healing and who had been identified as experiencing difficulty with adhering to treatment. Single semi-structured interviews were used and participants were asked to share key events in their care prompted by the question 'how are you coping with your leg ulcer?' Striving to maintain balance by developing strategies to cope with the physical effects of an unhealed ulcer as well as ensuring the care they received met their unique needs was central to the experience of participants. From the participant's perspective, however, nurses often showed little understanding of the complex issues patients were grappling with. Patients, in viewing nurse behaviour, often concluded that leg ulceration was an insignificant problem that nurses had little interest in. The need to establish and to maintain a trusting therapeutic relationship with patients is essential if they are to feel they matter, that they are important as individuals and that their suffering can be eased by sensitive collaboration.

The effects of antidepressant medication adherence as well as psychosocial and clinical factors on depression outcome among older adults

OBJECTIVE

To examine the contribution of medication adherence to 12-month depression scores in the context of other psychosocial and clinical predictors of depression in a sample of older adults treated for depression.

METHODS

Secondary analysis of a prospective cohort study involving 241 older patients undergoing depression treatment using a standardized algorithm. Depression was measured at baseline and 12-months post-baseline. Baseline predictor variables included antidepressant adherence, barriers to antidepressant adherence, four domains of social support, basic and instrumental activities of daily living (BADLs and IADLs), and clinical factors including past history of depression and medical comorbidities.

RESULTS

Nearly 28% of patients reported being nonadherent with their antidepressant medication. In bivariate analyses, greater antidepressant medication nonadherence, more medication barriers, poorer subjective social support, less non-family interaction, greater BADL and IADL limitations, poor self-rated health, higher baseline depression scores, and not having diabetes were related to higher 12-month depression scores. In multivariable analyses, greater medication nonadherence, not having diabetes, poorer subjective social support, greater BADL limitations, and higher baseline depression scores were related to higher 12-month depression scores.

CONCLUSION

Interventions should be directed toward improving antidepressant adherence and modifiable psychosocial variables.

A review of health behaviour theories: how useful are these for developing interventions to promote long-term medication adherence for TB and HIV/AIDS?

BACKGROUND

Suboptimal treatment adherence remains a barrier to the control of many infectious diseases, including tuberculosis and HIV/AIDS, which contribute significantly to the global disease burden. However, few of the many interventions developed to address this issue explicitly draw on theories of health behaviour. Such theories could contribute to the design of more effective interventions to promote treatment adherence and to improving assessments of the transferability of these interventions across different health issues and settings.

METHODS

This paper reviews behaviour change theories applicable to long-term treatment adherence; assesses the evidence for their effectiveness in predicting behaviour change; and examines the implications of these findings for developing strategies to improve TB and HIV/AIDS medication adherence. We searched a number of electronic databases for theories of behaviour change. Eleven theories were examined.

RESULTS

Little empirical evidence was located on the effectiveness of these theories in promoting adherence. However, several models have the potential to both improve understanding of adherence behaviours and contribute to the design of more effective interventions to promote adherence to TB and HIV/AIDS medication.

CONCLUSION

Further research and analysis is needed urgently to determine which models might best improve adherence to long-term treatment regimens.

Knowledge, attitude, and practices related to standard precautions of surgeons and physicians in university-affiliated hospitals of Shiraz, Iran

OBJECTIVE

To measure levels of knowledge, attitudes, and practice toward standard precautions (SP) in medical practitioners of Shiraz University of Medical Sciences affiliated hospitals in Iran.

METHOD

In this cross-sectional study, knowledge, attitude, and practice related to SP among four medical staff groups - surgeons, surgical residents, physicians and medical residents - were assessed using a questionnaire.

RESULTS

Across the four medical staffing groups the median levels of knowledge ranged from 6 to 7 (maximum score 9), median attitude scores were high ranging from 35 to 36 (maximum score 45), while median practice scores were low, ranging from 2 to 3 (maximum score 9). A moderate relationship between knowledge and attitudes was found in surgical residents and medical residents (r=0.397, p=0.030 and r=0.554, p=0.006, respectively). No significant correlation was found between knowledge and practice between the groups. A significant but poor (r=0.399, p=0.029) relationship between attitude and practice was found in surgical residents.

CONCLUSION

Specific training programs may have to target newly graduated medical practitioners to establish acceptance of appropriate practices that will enable them to adopt and adhere to SP while their older counterparts may require more intense continuous assistance.

Rates and predictors of adherence with atypical antipsychotic medication: a follow-up study of adolescent inpatients

BACKGROUND

The use of atypical antipsychotics is increasing in adolescent populations, but little is known about adherence with these treatments. This study examined postdischarge adherence of adolescents treated as inpatients with either olanzapine or risperidone.

METHODS

Eighty-six (86) adolescent inpatients (43 per treatment) were contacted an average of 10 months (range, 90 days to 18 months) after discharge from the hospital. A structured interview examined compliance, side effects, and subjective impressions regarding the efficacy of treatment. Clinical symptoms rated by clinicians, self-reports from patients, hospital chart diagnosis, treatment group (risperidone/olanzapine), and demographic factors were used to predict compliance, as were the occurrence of side effects and subjective impressions of the efficacy of treatment.

RESULTS

Forty-five percent (45%) of the patients were adherent with their medications, while only 12% discontinued treatment on their own, and 43% stopped medication at the request of their parent or a physician. Medication status and symptom severity did not predict nonadherence, and the only diagnosis related to adherence was substance abuse. The only side effect that predicted nonadherence was rapid weight gain during the hospitalization; this was slightly more common in olanzapine-treated patients. Nonadherent patients' subjective impressions of efficacy were no different from the patients who continued their medications, but the patients who stopped medication on their own were more likely to also have failed to attend recommended psychotherapy as well.

IMPLICATIONS

Failure to continue recommended treatment with atypical antipsychotics was most common in cases who did not comply with other aspects of the discharge plan. Efficacy of the medication did not predict nonadherence, as half of the noncompliant subjects stated that the medication had been helpful. Rapid weight gain also predicted nonadherence, but subjective impression of long-term weight gain was not different across adherence or treatment status. These data tentatively suggest that in adolescent patients, tendencies toward general uncooperativeness and substance abuse may be at least as important as the occurrence of common side effects in the determination of medication adherence.

Spontaneous treatment discontinuation in panic disorder patients treated with antidepressants

OBJECTIVE

We examined the relationships between long-term treatment response, side-effects and drug discontinuation in panic disorder (PD)-agoraphobia.

METHOD

A total of 326 patients were naturalistically treated with antidepressants and followed for a period of 3 years. All patients were evaluated by means of the Panic Disorder/Agoraphobia Interview and the Longitudinal Interview Follow-up Examination (LIFE-UP).

RESULTS

A total of 179 patients interrupted pharmacological treatment. Among them, 26.8% were not traceable; 36.9% had deemed further contact with the psychiatrist unnecessary because of remission. Other reasons for interruption were: ineffectiveness (18.4%), side-effects (10.6%) and personal reasons (7.3%). Patients who interrupted pharmacological treatment because of symptom remission remained in the study for a longer period than those patients who interrupted their treatment because of inefficacy.

CONCLUSION

In the long-term treatment of PD with antidepressants, a high percentage of patients who have achieved symptom remission tend to default from further treatment; adherence to long-term treatment with antidepressants was predicted by severe and long-lasting symptomatology.

Use of an on-line pager system to increase adherence to antiretroviral medications

Adherence to antiretroviral therapy is critical for treatment success. Antiretroviral therapy typically requires multiple pills at multiple dosing times. To address this, we tested the feasibility, utility, and efficacy of a customizable reminder system using pagers, which were programmed using web-based technology, to increase and maintain proper adherence in patients with pre-existing adherence problems. After a two-week monitoring period with an electronic pill-cap, participants with less than 90% adherence were randomized to continue monitoring or to receive a pager. The group who received the pagers had greater improvements in adherence from baseline to Week 2 and Week 12 than those who monitored their medications only. However, adherence in both groups at the outcome assessments points was still poor. While the provision of a reminder system helped improve adherence, it is likely that more intensive interventions are required for patients with pre-existing problems.

The 5-factor model of personality and antidepressant medication compliance

OBJECTIVE

Medication noncompliance is a significant problem for effective pharmacologic treatment of major depressive disorder (MDD). Attempts to explore predictors of compliance have primarily focused on demographic characteristics; for the most part, these have been shown to be unrelated to compliance. Conversely, the relation between personality characteristics and compliance has been relatively understudied. The primary purpose of this study was to explore the relation between personality characteristics and compliance with antidepressant medication in patients with major depressive disorder (MDD).

METHOD

Over 14 weeks, we evaluated a sample of outpatients (n = 65) who were receiving antidepressant treatment. We monitored compliance electronically, using the Medication Event Monitoring System. We assessed personality characteristics with the NEO Five-Factor Inventory-Revised. We also assessed depression severity and the frequency and severity of side effects.

RESULTS

Extraversion was a significant negative predictor of compliance. This was largely explained by the relation between compliance and the Activity facet within Extraversion. We also found a negative relation between the Feelings facet and compliance, while the Modesty facet was a significant positive predictor of compliance with antidepressant medication. Neither severity of depression nor side effects predicted compliance.

CONCLUSIONS

These results suggest that correlates of personality are important, although frequently ignored, predictors of compliance with antidepressant medication. Identifying predictors of medication compliance may help in the development of individualized treatment regimens and lead to improved therapeutic outcome in the treatment of MDD.

Clinical pharmacology, clinical efficacy, and behavioral toxicity of alprazolam: a review of the literature

Alprazolam is a benzodiazepine derivative that is currently used in the treatment of generalized anxiety, panic attacks with or without agoraphobia, and depression. Alprazolam has a fast onset of symptom relief (within the first week); it is unlikely to produce dependency or abuse. No tolerance to its therapeutic effect has been reported. At discontinuation of alprazolam treatment, withdrawal and rebound symptoms are common. Hence, alprazolam discontinuation must be tapered. An exhaustive review of the literature showed that alprazolam is significantly superior to placebo, and is at least equally effective in the relief of symptoms as tricyclic antidepressants (TCAs), such as imipramine. However, although alprazolam and imipramine are significantly more effective than placebo in the treatment of panic attacks, Selective Serotonin Reuptake Inhibitors (SSRIs) appear to be superior to either of the two drugs. Therefore, alprazolam is recommended as a second line treatment option, when SSRIs are not effective or well tolerated. In addition to its therapeutic effects, alprazolam produces adverse effects, such as drowsiness and sedation. Since alprazolam is widely used, many clinical studies investigated its cognitive and psychomotor effects. It is evident from these studies that alprazolam may impair performance in a variety of skills in healthy volunteers as well as in patients. Since the majority of alprazolam users are outpatients, this behavioral impairment limits the safe use of alprazolam in patients routinely engaged in potentially dangerous daily activities, such as driving a car.

A family group approach to increasing adherence to therapy in HIV-infected youths: results of a pilot project

This paper describes the development of a novel, pilot program in which a combined family group and peer approach were used to increase adherence to antiretroviral therapy in HIV-infected youths. Twenty-three HIV-positive youths, 15-22 years of age and 23 family members or "treatment buddies" participated in one of three 12-week programs. The intervention had six biweekly family and youth education sessions and six biweekly youth-only education sessions. Devices to increase adherence to antiretroviral therapy such as pill boxes, calendars, and watch alarms were introduced at youth-only sessions. Eighteen of the 23 youths completed a group. Ninety-one percent of youths self-reported increased adherence to medications after completion of a group. Four participants experienced a one-log reduction in viral loads to undetectable levels during the intervention. Two participants continued to decline antiretroviral medications at the end of the intervention and demonstrated no decrease in viral load. Participants tested five devices and rated the multiple alarm watch as the best aid for improving adherence to medication. Family/treatment buddies rated the overall program as highly helpful, citing social support as most valuable. An unanticipated benefit was an increase in other health behaviors, including medical and dental appointments, hepatitis B and influenza immunizations, and referrals to mental health and substance abuse treatment.

Adequate self-care of dialysed patients: a review of the literature

The purpose of this article is to clarify the concept: 'adequate self-care of patients treated with hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD)'. This was done by the specification of Orem's general definition of self-care and a review of the literature. Adequate self-care behaviours for preventing and regulating pathological processes and related disabilities e.g. following dialysis and medication prescriptions as well as diet and fluid regimens are well documented. Adequate self-care behaviours aimed to promote personal well-being or development are less well documented. The authors suggest that use of the concept of adequate self-care would enlarge the scope of the disease management of HD and CAPD patients. Further research should focus on systematically investigating self-care activities of dialysed patients and their contribution to health and quality of life outcomes.

Therapeutic compliance methodologies in HIV-infection treatment: A comparative study

Compliance with HIV treatment has been studied extensively. Following the introduction of tritherapy, its importance and implications have changed. Antiretroviral treatments entail taking up to 20 pills a day at set hours, for which there are often numerous undesirable and even toxic side effects. These therapeutic constraints lead to what is labeled greater or lesser compliance. Certain factors such as side effects, modes of contamination, and trust in physicians appear to be more closely linked to noncompliance than others. A recurring problem is how to assess this compliance. There are two types of measures that serve this purpose: direct (biological) or indirect (interviews, questionnaires). It is often very difficult to know how authors actually proceed in assessing their patients' compliance. To determine this, we analyzed 27 of the 310 studies published between 1990 and 2000 on therapeutic compliance in HIV-infected patients. These 27 studies were not chosen because they are a statistically representative sample of the related literature, but because they account quite well for the different types of methods used to measure compliance with HIV treatment. Our analysis shows that compliance measures are quite diverse and can be either a combination of direct and indirect measures, or consist of one or more direct measures or only indirect measures. These three methodological orientations are discussed first. The limits and biases of self- and hetero-compliance assessment, so often neglected, are studied next. Finally, problems related to the temporal facet of compliance behavior are analyzed, namely definition of the concept, need for a more precise theoretical elaboration, and the place of health psychology in relation to the medical sciences.

Involvement and satisfaction: a Norwegian study of health care among 1,024 patients with rheumatoid arthritis and 1,509 patients with chronic noninflammatory musculoskeletal pain

OBJECTIVE

To investigate involvement in and satisfaction with health care among patients with rheumatoid arthritis (RA) and persons with chronic noninflammatory musculoskeletal pain, to identify target areas for improvement.

METHODS

Data were collected from postal surveys carried out in 1994 in Oslo, Norway, with 1,542 patients with RA and 10,000 randomly selected adults. Patients with RA and persons with noninflammatory musculoskeletal pain were asked 3 questions about their involvement with treatment and 1 question about their satisfaction with health care. Levels of involvement and of satisfaction were related to demographic measures, health status measures, use of health services, and, for patients with RA, self-efficacy.

RESULTS

Of the respondents with RA (n = 1,024), 40% scored low on at least 1 question on involvement and 11% reported global dissatisfaction. Being young, well educated, physically disabled, in good mental health, and self-efficient and having visited a rheumatologist in the last 12 months were associated with a high level of involvement; being female and having a low pain level, good mental health, and high self-efficacy were associated with satisfaction with health care. Of persons with noninflammatory musculoskeletal pain of more than 5 years duration (n = 1,509), 57% scored low on at least 1 question on involvement and 27% reported global dissatisfaction. Being well educated, having visited a general practitioner in the last 12 months, and having ever visited a rheumatologist were associated with a high level of involvement. Being older and having a low pain level and good mental health were associated with satisfaction. A low score on involvement was a strong independent predictor of global dissatisfaction in both groups.

CONCLUSION

High education level and health service provided by rheumatologists were consistently associated with a high level of involvement. Good mental health and high involvement were associated with satisfaction with the care received. Efforts to achieve a higher level of patient involvement should especially be directed toward patients with low education, emotional distress, and a chronic physical disorder.

Self-efficacy in chronic illness: the juxtaposition of general and regimen-specific efficacy

Changes in lifestyle are difficult for most people but necessary for those with a chronic illness, for whom changes may involve, among other adjustments, learning new behaviours and/or modifying one's lifestyle. The ease with which such changes occur depends on the person's efficacy beliefs and outcome expectations. This paper will discuss the conceptual issues related to self-efficacy: general, domain, and specific. Examples will be drawn from the health-related behaviour changes required to manage diabetes and rheumatoid arthritis. For this paper, regimen-specific or task-specific behaviour refers to the multiple tasks that the person carries out for management of their chronic illness. Confounding the issue of perceived efficacy (general, domain or specific), is the fact that compliance with all aspects of a recommended self-care regimen will not necessarily result in metabolic control for the person with type 1 diabetes mellitus, weight loss for the person with type 2 diabetes mellitus, or pain control for the arthritic person.

A patient diary as a tool to improve medicine compliance

Compliance is a well recognised but still unresolved health problem; improvement of compliance to treatment would increase cost-effectiveness. One of the current methods used to measure treatment compliance in a clinical drug trial is through the use of a patient diary. In order to interpret data in these diaries it is important to also assess how compliant patients are in completing diaries. Patient compliance of standard diary completion was measured in 69 patients with perennial rhinitis, who were randomised into a double blind, placebo controlled trial with a new corticosteroid drug. During 3 months the patients were instructed to complete a diary twice a day for the following parameters: rhinitis signs and symptoms, dosage times, concomitant medication, use of rescue medication and comments. Diaries were reviewed by the physician at scheduled visits. Twenty patients (30%) completed their diaries for all items perfectly, while 62 patients (94%) completed more than 95% of all items. The compliance of diary completion in a well controlled trial is high. Overall completion of the diary was not influenced by age, gender, race, use of concomitant medication or treatment failure. Significant correlations were found for study duration and physician. This study suggests that completion of a daily diary is positively correlated with patient compliance in medication intake. Physicians could consider using diaries to try to improve compliance. More explicit investigations are needed.

Evaluation of a nurse-run asthma school

Important aims of the study were to investigate whether an educational program (the 'Asthma School') directed by a nurse led to improved knowledge of the disease, to improved self-medication and self-management and to improved, self-rated, functional status. A total of 32 patients (6 males, 26 females, mean age 43 years) was included. The following methods were used to collect the data before and one year after the Asthma School was completed; two study-specific questionnaires for collecting demographic data and measuring different aspects of the patients' knowledge of the disease and its treatment, monthly diary cards, lung-function tests (FEV1) and the Sickness Impact Profile (SIP) questionnaire. The main results of the study were an improved knowledge of the disease and its treatment, better self-management, i.e. more frequent use of the peak expiratory flow meter (PEF-meter) and use of inhaled bronchodilators on an as-required basis, fewer patients on sick-leave and a better, self-rated, physical health status. However, in spite of these encouraging results, the lungfunction was found to be unaffected, no pronounced changes in the use of asthma drugs could be found and the patients' need for medical care remained the same.

Patient-treatment matching improves compliance of alcoholics in outpatient treatment

In chronic medical disorders, patient compliance is very poor and often less than 50%. The purpose of this investigation was to determine whether the proper matching of patient, treatment, and therapist would improve patient compliance in the outpatient treatment of alcoholics. We randomly placed 119 alcoholics who had commenced protracted outpatient treatment for alcoholism in either low or high structured treatments. These 119 patients were offered 12 months of individual treatment. Interruption of this treatment was recorded as noncompliance. The treatment courses were expressed in survival curves. The consequence of compliance for long-term prognosis was described by means of the Addiction Severity Index. The form of treatment in itself had no importance for compliance. However, correct matching of a patient and a treatment structure resulted in a compliance rate of 63% as opposed to 38% compliance among mismatched patients. Twenty-four months after the initiation of treatment, patients in the compliance group had a significantly higher level of function than those in the noncompliance group. Our investigation of alcoholics involved in outpatient treatment shows that the correct matching of patients and treatment structure improves compliance and long-term prognosis. It is hoped that the present investigation will generate interest in future research on correct matching to gain improved compliance in patients with a chronic medical disorder.

Satisfaction as a determinant of compliance

In this study the relation between satisfaction and compliance is examined in terms of specificity and predictive value. Satisfaction is assumed to be a determinant of compliance, especially if both concepts are measured at the same level of specificity (i.e., a dental level). A total of 176 subjects reported their satisfaction with dental visits and the dental practice, their dental compliance and their general tendency to comply. The results show a relation between satisfaction and compliance and that compliance can be predicted by satisfaction. Surprisingly, the relation between dental satisfaction and general compliance is stronger than the relation between dental satisfaction and dental compliance. This finding can be explained by the possible relation between different levels of compliance and the complexity of the concept dental compliance.

Home nebulized therapy for patients with COPD: patient compliance with treatment and its relation to quality of life

STUDY OBJECTIVES

To assess compliance with home nebulized therapy in patients with COPD.

DESIGN

Patients' home nebulizers were replaced with nebulizers that recorded the date and time of each treatment over a period of 4 weeks. Poor compliance was defined as taking <70% of the prescribed dose (or <60% for those prescribed treatments five or more times daily).

SETTING

Patients were seen at the hospital COPD outpatient clinic. The compliance data obtained were recorded while they were at home.

PATIENTS

Ninety-three patients aged 44 to 76 years (mean, 64.9 years) were recruited from the hospital nebulizer database.

MEASUREMENTS

Patients completed a self-reported quality of life scale, the St. George's Respiratory Questionnaire (SGRQ), both before (SGRQ1) and after (SGRQ2) the 4-week study period to look at whether quality of life was either predictive of or subsequent to level of compliance.

RESULTS

Data were obtained from 82 patients. Mean compliance was 57% (range, 0 to 124%). Thirty-six (44%) patients were compliant and 46 (56%) were poorly compliant. There was no difference between the two groups in age or sex distribution. Compliance was negatively correlated with the total score on the SGRQ2 (p=0.03).

CONCLUSION

The study shows that levels of compliance with nebulized therapy are low in a large proportion of patients with COPD and that patients with low levels of compliance report greater impairment in their quality of life.

Adherence: a matter of self-efficacy and power

This paper examines the relationship between self-efficacy and social power (expert and referent) and how the application of this relationship, leads to client adherence and compliance. Referent power is defined, including methods that health care professionals may use to develop and apply referent power. Expert power is defined and addressed in the context of referent power, self-esteem and self-efficacy as a means of promoting adherence. Self-efficacy as a concept is defined and explored in the context of social power. The relationships between self-efficacy and social power (expert and referent) are shown as important determinants of adherence and compliance. The theory of the application of referent and expert power in relationship with self-efficacy has been compared with an effective programme, yielding high compliance, at Western Psychiatric Institute and Clinic, showing the theory's relevance and applicability in determining compliance. Explored are the reasons for non-compliance in the elderly population and how the theory model can remedy these detriments for compliance. The empowerment of elderly patients through the application of this theory to medication compliance is examined. The determination of adherence and compliance is shown by the application of the relationship between self-efficacy and both expert and referent power.

Compliance during treatment with antidepressants

Compliance has become a topic of intense investigation and debate during the past two decades. The present review first examines to what factors the exponential increase in research studies on the topic can be attributed. A second part summarizes the history of the concept, the definitions and measurements of compliance and the estimations of compliance and non-compliance. Studies searching for relevant components of compliance behavior can be divided in two groups. A first group of publications originates from a biomedical and pharmaceutical approach, and investigates which characteristics of illness, of drug regimen or drug side effects, of patients, doctors or their practices can predict the variance in compliance. The implicit aim of these studies is the development of strategies leading to increased compliance. A second group of publications originates from medical psychology (psychodynamic, cognitive-behavior and interactional considerations) and investigates why a given patient is compliant or not, sometimes even suggesting that non-compliance can even be a meaningful response. The present review suggests that the relation between the occurrence of side effects and non-compliance during treatment with antidepressant drugs is more complex than usually accepted and that, in case of non-compliance, finding an equilibrium between authoritarian tactics and passive avoidance does remain one of the challenges in daily practice.