Obedience and motivation as mechanisms for adherence to medication: a study in obese type 2 diabetic patients

How is Patient Adherence Possible? A Novel Mechanistic Model of Adherence Based on Humanities

Patient non-adherence is a major contemporary medical issue because of its consequences in terms of frequency, morbidity and mortality, and health care costs. This article aims to propose a mechanistic model of adherence based on the tenet that non-adherence is the default option, as long-term adherence in chronic diseases requires sustained effort. The real question becomes, how is patient adherence possible? By focusing on adherent patients, the paper explains the mental mechanisms of adherence using concepts largely drawn from humanities, philosophy of mind, and behavioral economics and presents the findings of empirical studies supporting these hypotheses. The analysis first demonstrates the relationship between patient adherence and temporality and the influence of character traits. Further, it points out the importance of habit, which allows adherence to become non-intentional, thereby sparing patients' cognitive efforts. Finally, it points out the importance of the quality of the interaction between the person with a chronic disease and the health professional. These features explain why adherence is a syndrome (the healthy adherer phenotype), separating people into those who are safe and those who are at risk of non-adherence, non-control of diabetes, and complications. The concepts presented in this article summarize 20 years of personal clinical and philosophical reflection on patient adherence. They are mainly illustrated by examples from diabetes care but can be applied to all chronic diseases. This novel model of adherence has major practical and ethical implications, explaining the importance of patient education and shared medical decision-making in chronic disease management.

Factors Influencing Treatment Adherence Among Drug-Sensitive Tuberculosis (DS-TB) Patients in Armenia: A Qualitative Study

PURPOSE

Despite the availability of effective treatment, tuberculosis (TB) is still one of the leading causes of mortality around the globe. Poor adherence to treatment challenges TB management both globally and locally. Proper adherence to treatment contributes to successful outcomes and prevents the development of drug-resistant forms of TB.

PATIENTS AND METHODS

We conducted a qualitative study to identify and describe the factors that facilitated treatment adherence among drug-sensitive TB (DS-TB) patients in Armenia. Sixteen in-depth interviews (IDIs) with former DS-TB patients, two IDIs with family members of former DS-TB patients, and a focus group discussion with healthcare providers who manage DS-TB patients were conducted. The educational and ecological assessment component of the PRECEDE-PROCEED model was applied as a conceptual framework to guide the interview content and data analysis.

RESULTS

Former patients' awareness of TB and its treatment, beliefs about TB, trust in TB healthcare providers, and a sense of responsibility were the most common factors that predisposed them to complete the treatment. Support received from providers, family, and friends, a desire to avoid TB-associated stigma, and good tolerance of TB medications were the main reinforcing factors. Enabling factors included a relatively simple regimen of TB treatment and accessibility and affordability of TB services.

CONCLUSION

The findings of the study provide new perspectives on factors that facilitate adherence to long-term therapies, such as TB. Interventions that aim to invoke a patient's sense of responsibility and positive beliefs about TB as well as engage families might promote the successful completion of treatment.

An Unsafe/Safe Typology in People with Type 2 Diabetes: Bridging Patients' Expectations, Personality Traits, Medication Adherence, and Clinical Outcomes

BACKGROUND

Support programs are provided to people with diabetes to help them manage their disease. However, adherence to and persistence in support programs are often low, making it difficult to demonstrate their effectiveness.

AIM

To identify the determinants of patients' perceived interest in diabetes support programs because it may be a powerful determinant of effective participation in such programs.

PATIENTS AND METHODS

An online study conducted in April 2021 in metropolitan France on 600 people with diabetes recruited from a consumer panel. A 64-item psychosocial questionnaire including a question asking to evaluate the helpfulness of a support program was used. Univariate, multivariate, and multiple correspondence analyses were performed.

RESULTS

The existence of a typology, known as Unsafe/Safe, was discovered, in which patients with type 2 diabetes respond in two distinct ways. Type U (unsafe) patients, who believe that a support program would be helpful, are more likely to be nonadherent to their treatment, have high hemoglobin A1c levels, have at least one diabetic complication, lack information regarding their disease and treatment, rate the burden of their disease and impairment of their quality of life as high, worry about their future, and are pessimistic. Type S (safe) patients have the opposite characteristics. Type U patients can be dichotomized into two broad classes: one in which they lack information regarding disease and treatment and the other in which alterations in the quality of life and burden of the disease predominate. Insulin-treated patients give more importance to the lack of information, whereas noninsulin-treated patients complain primarily about the burden of the disease and impairment of quality of life.

CONCLUSION

This study describes this new U/S typology, proposes a simple method based on a nine-item questionnaire to identify type U patients by calculating a Program Helpfulness Score described herein, and clarifies the nature of the intervention to be provided to them. This novel approach could be applied to other chronic diseases.

Intentionality in adherence to long-term therapies. Results from an online survey of 3,001 patients with cardio-metabolic pathologies in France

PURPOSE

Some patients make a rational choice not to follow medical prescriptions; others fail to take their medications for reasons beyond their control, such as mere forgetfulness or a weak medication routine. The aim of this study was to elucidate the functioning of patient intentionality in medication adherence.

PATIENTS AND METHODS

This online study was conducted in metropolitan France in 2019. A cross-sectional survey of 50 questions was conducted with 3001 respondents diagnosed with diabetes, hypertension, and/or hypercholesterolemia identified from a panel of 54,000 people. These questions included a validated six-item questionnaire to detect nonadherence, two questions to detect intentional nonadherence by patients, and three questions on the effects of habit. Our questionnaire also included questions on the feelings of respondents regarding their doctor's attitude to their problems and needs, their trust in general practitioners (GP) and specialists, their sense of being involved in treatment decisions, and the influence of side effects and habits on patients' adherence. This study used the strategy of focusing on strictly adherent patients in the hope of finding ways to improve adherence. For this reason, we defined adherence as the absence of a positive response to the 6-item nonadherence screening questionnaire.

RESULTS

Of 3001 respondents, 1804 were diagnosed with hypertension, 1458 with hypercholesterolemia, and 774 with diabetes. Of the total number of patients, 72% were afflicted with one disease, 21% with two ailments, and 7% with three simultaneous illnesses. One-third (33%) of the patients did not tender a positive answer to the adherence questionnaire and were deemed adherent. 1) Thirty-two percent of the patients reported occasionally omitting their medication deliberately, and 84% said they had a reason for missing doses. These statements suggesting intentional nonadherence were negatively associated with adherence as identified via multivariate analysis (P = 0.0012 and P < 0.0001, for the first and second statement, respectively). 2) Univariate analyses revealed strong associations (P < 0.0001) between strict adherence on one hand and lack of intentional nonadherence, patient age, absence of drug side effects, taking drugs by habit, feeling involved in treatment decisions, getting information about treatment, and disease, and trust in doctors, on the other hand. 3) Specifically, univariate analysis of the absence of reported side effects revealed strong associations (P < 0.0001) with adequate information about medicines and diseases and trust in GP. These original data were consistent with the concept of the nocebo effect. 4) We observed a strong association between the absence of intentional nonadherence (statement of never deliberately missing medication) and respondent statements about generally sticking to the routine (P < 0.0001), ie, "I take my medication because I am used to taking it." This important result suggests that patients are strictly adherent in two ways: the absence of intentional nonadherence and reliance on habit, which we term as "unintentional adherence." 5) Finally, a multiple correspondence analysis illustrated all statistically significant relationships found in this study.

CONCLUSION

We present a new global model of adherence in which patient adherence was improved both by reducing intentional nonadherence and by promoting the abovementioned unintentional adherence by habit. This model highlights the role of shared decision-making and the trust felt by patients in their doctors. These results could exert a major impact on medical practice and education by demonstrating the importance of physicians' attitudes, involving the patient in decisions (shared decision-making), offering information about medicines and diseases (patient education), understanding the problems of patients, and taking their needs into account (empathy). The development of these attitudes should be an important aspect of the medical curricula.

The Effect of Early Response to GLP-1 RA Therapy on Long-Term Adherence and Persistence Among Type 2 Diabetes Patients in the United States

BACKGROUND

Treatment adherence and persistence are crucial to achieve glycemic control in patients with type 2 diabetes (T2D). Early response to a new therapy may lead to improved treatment adherence and associated outcomes.

OBJECTIVE

To assess the effect of early response to glucagon-like peptide-1 receptor agonist (GLP-1 RA) therapy, as indicated by reduced hemoglobin A1c (A1c) and body weight, on long-term adherence and persistence.

METHODS

Adults aged ≥ 18 years with T2D initiated with GLP-1 RA therapy after January 1, 2010, were identified from the IBM Explorys Therapeutic Dataset. Patients were required to have health care utilization ≥ 6 months before and ≥ 18 months after the index prescription. Changes in A1c and body weight from baseline through 6 months were assessed for all patients; early response was defined by > 1% reduction in A1c and > 3% reduction in body weight within 3-6 months. Adherence (assessed as the proportion of days covered [PDC] ≥ 80%) and nonpersistence/discontinuation (indicated by a gap in therapy ≥ 60 days) over 18 months were evaluated among early responders versus nonresponders. Multivariable logistic regression was used to assess the effect of early response to GLP-1 RA therapy on adherence and discontinuation over 18 months.

RESULTS

Among 8,329 identified patients, 33.3% and 31.2% experienced early response as indicated by reductions in A1c > 1% point and in body weight > 3% from baseline, respectively. Significantly higher proportions (P < 0.001) of early responders in both reduced A1c and body weight were adherent over 18 months compared with patients without an early response (A1c: 45.0% vs. 37.1%; body weight: 43.3% vs. 38.0%). Significantly lower proportions (P < 0.001) of early responders discontinued over 18 months compared with patients without an early response (A1c: 61.4% vs. 67.9%; body weight: 61.9% vs. 67.5%). After controlling for baseline demographic and clinical characteristics including baseline weight, baseline A1c, oral antidiabetes drug use, insulin use, and the presence of comorbidity of diabetes, patients were more likely to be adherent over 18 months if they had reductions in A1c > 1% (OR = 1.59, 95% CI = 1.36-1.85) or body weight reduction > 3% (OR = 1.18, 95% CI = 1.02-1.36) at 3-6 months compared with those without an early response. Similarly, the early responders had significantly lower likelihood of discontinuation compared with those without early response (A1c > 1%; OR = 0.62, 95% CI = 0.53-0.72; body weight > 3%; OR = 0.81, 95% CI = 0.70-0.94).

CONCLUSIONS

Early response to GLP-1 RA therapy was associated with significantly increased adherence and reduced likelihood of discontinuation.

DISCLOSURES

Funding to conduct this study was provided to IBM Watson Health by Novo Nordisk A/S. The analysis was conducted independently by IBM Watson Health. Novo Nordisk A/S and IBM Watson Health collaborated on study design and interpretation of results. At the time of this study, Durden and Laing were employed by IBM Watson Health and received funding from Novo Nordisk to conduct this study. Fowler is employed by IBM Watson Health. Panton and Mocevic were employed by Novo Nordisk while this study was conducted. A portion of these results were presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2018; April 23-26, 2018; Boston, MA, where it was awarded with a bronze ribbon.

Implication Of Character Traits In Adherence To Treatment In People With Gout: A Reason For Considering Nonadherence As A Syndrome

OBJECTIVE

Various aspects of nonadherence to therapy (including medication and lifestyle nonadherence) often appear together. Here we report the association between treatment adherence in gout and the two character traits of patience and obedience, which may explain this observation.

METHODS

Data were collected from a cross-sectional study conducted in a French cohort of 1441 adult patients. Patience was assessed using the choice between receiving €1500 in 1 year or €500 immediately. Obedience was evaluated with a single question assessing the use of the seatbelt in the rear seat of a car. Adherence to recommendations for medication, beverage, food and physical activity and smoking status was assessed using self-report questionnaires.

RESULTS

Patience and obedience were strong determinants of adherence to medication in multivariate analysis (OR 2.056, 95% CI [1.414-2.989], P< 0.001; OR 1.844, 95% CI [1.273-2.671], P=0.001). In univariate analysis, adherence to medication was also associated with compliance with dietary directives (P<0.001), lower alcohol consumption on an ordinary day (P< 0.001), never consuming soda (P<0.001) or beer (P<0.001), practice of physical activity (P=0.002), being a nonsmoker (P<0.001) and monitoring serum levels of uric acid regularly (P=0.011). Multiple-correspondence analysis illustrated the associations of these different aspects of adherence (medication, diet and exercise, smoking status and monitoring of disease control) with patience and obedience. Finally, we observed a link between patience and obedience (P< 0.001).

CONCLUSION

Character traits, which shape preferences, may cause the clustering of different aspects of nonadherence in the form of a syndrome, elucidating the still enigmatic link between nonadherence to placebo and mortality in randomised clinical trials. This concept may also explain, at least in part, the difficulty of improving adherence to long-term therapies and may lead to ethical issues.

Temporality in chronic diseases and adherence to long-term therapies: From philosophy to science and back

This narrative review exhibits the construction and validation of a hypothesis to explain how treatment non-adherence in people with chronic disease, a major issue in contemporary medicine, occurs. I propose that non-adherence to long-term therapies is at least in part due to failure to prioritize the future, which is caused by a condition I dub disruption in time projection. This article gives the rationale for this hypothesis, which is largely grounded on philosophical arguments. Then, it demonstrates the plausibility of the hypothesis: on the one hand, it is consistent with certain epidemiological data found in the literature. On the other, it is possible to predict the underlying mechanisms of this lack of prioritization from recent achievements of neuro-economics and neuroscience. Next, it reviews empirical data that provide an experimental verification for this explanatory hypothesis. Finally, a general evolutionary and philosophical meaning for adherence is proposed, considering the advantages of its preconditions, namely, patience and foresight.

Holistic psychosocial determinants of adherence to medication in people with type 2 diabetes

BACKGROUND

The aim of this study was to determine whether adherent and non-adherent patients with type 2 diabetes can be differentiated according to psychosocial characteristics.

METHODS

A total of 1214 patients were included in the analysis. Data were derived from a cross-sectional observational study of adults with diabetes of the Access Santé (Access Health) panel of Kantar Health France. Patients completed a questionnaire on adherence to medication, psychological determinants (trust in physicians, constancy of habits, patience, temporal horizon, health locus of control, obedience, psychological reactivity, prevention vs promotion, optimism vs pessimism) and social deprivation.

RESULTS

Of these 1214 subjects, 46.2% were considered strictly adherent to antidiabetic medication, as reflected by negative answers to all six questions suggesting a non-adherent behaviours, whereas 48.9% provided 1-2 positive answers and 4.9% provided 3-6 positive answers, and were considered non-adherent. In addition to the effect of younger age (P=0.03), multivariate logistic regression analysis demonstrated the following psychosocial determinants of non-adherence: chance locus of control (P=0.02); lack of trust in physicians (P=0.010); and pessimism (P=0.021). Multiple factor analysis identified adherence and social deprivation as dimensions separating three distinct patient populations: (i) non-adherent; (ii) adherent and socially deprived; and (iii) adherent and non-socially deprived. It also revealed that patience, obedience, cautious behaviour, optimism, trust in physicians and constancy of habits were associated with adherence.

CONCLUSION

Of the multiple determinants of adherence, trust in physicians and constancy of habits represent modifiable factors, and constitute targets to prevent non-adherence because they can be reinforced through patient education and improved physician - patient relationship. Also, psychosocial determinants of adherence differ widely between socially deprived and non-deprived patients.

Disruption in time projection and non-adherence to long-term therapies

OBJECTIVE

Patients' non-adherence to medical prescriptions is a crucial issue in contemporary medicine because it can jeopardize care efficacy. Non-adherence is especially frequent in patients with chronic diseases. In this article, we propose that a particular condition, which we call disruption in time projection, is a cause of non-adherence to medication therapies in chronic diseases.

METHODS

A questionnaire was administered to 120 hospitalized people with type 2 diabetes addressing three psychological constructs defining time projection: patience/impatience in a fictive monetary scenario (preferring to receive €1,500 in 1 year or €500 today), magnitude of temporal horizon (greater or lesser ability to imagine future events) and perception of the degree of physical similarity of current self to self at 1 year, 5 years and 10 years from the present. In addition, the questionnaire evaluated adherence to medication, social deprivation and depression.

RESULTS

In the multivariate analyses, two factors were associated with adherence to medication: patience (P<0.001) and long temporal horizon (P=0.006). Two factors were associated with HbA1c ≥8% (64 mmol/mol): non-adherence to medication (P=0.003) and short temporal horizon (P=0.011). Three factors were associated with long temporal horizon: adherence to medication (P<0.001), patience (P<0.001) and the existence of grandchildren (P=0.002). Social deprivation (P<0.001), non-adherence (P<0.001), female gender (P=0.002) and short temporal horizon (P=0.050) were associated with impatience. Finally, an association of adherence to expected similarity in the future to current self, impatience, short temporal horizon, social deprivation and depression was also shown in a multiple correspondence analysis.

CONCLUSION

What we termed a disruption in time projection may be a unique determinant for non-adherence to long-term therapy and, therefore, may influence the outcome of chronic diseases. We hypothesize that this is involved in both intentional and unintentional non-adherence and that it represents the loss of a protective mechanism. If this novel concept is to be confirmed in other settings and generalized to other chronic diseases, the recognition of its role in disease prognosis may help orient the teaching and practice of medicine.

[Factors associated with medication non-adherence in uncontrolled hypertensive males and females: ODACE study]

OBJECTIVES

The aim of this study was (1) to measure adherence in males and females with uncontrolled hypertension, and (2) to identify factors associated with non-adherence to antihypertensive medication.

PATIENTS AND METHODS

Each general practitioner (GP) should include the first two male and the first two female patients with uncontrolled treated hypertension. Adherence to antihypertensive treatment was estimated by the GP and using the French League Against High blood pressure (FLAH) self-administered questionnaire. A stepwise logistic regression analysis was used to identify factors associated with non-adherence on the FLAH scale, independently in males and in females.

RESULTS

A total of 1630 males and 1612 females were included in the analysis. Adherence to treatment was significantly better in females or when estimated by the GP. Lack of motivation was the first factor associated with poor adherence in both sexes. Considering hypertension as a simple anomaly and not a disease that can lead to cardiac or cerebral disorders was the second common parameter in both sexes. Other common factors were: having monthly periods of financial difficulties in facing his/her needs and absence of regular screening for colon cancer.

CONCLUSION

Adherence to treatment is better in uncontrolled hypertensive females. Poor adherence is mainly associated with non-clinical factors. The lack of motivation is the most important element.

Achieving HbA1c targets in clinical trials and in the real world: a systematic review and meta-analysis

PURPOSE

To review the proportion of diabetic patients reaching recommended therapeutic goals, as reported in intervention trials and observational studies, and to analyse the factors associated with success or failure in achieving these targets.

METHODS

A systematic review and meta-analysis through a Medline and Embase search for "diabetes" and "HbA1c" has been performed between 1 January 1995 and 1 March 2012 on randomised clinical trials and observational studies on type 1 (T1DM) or type 2 diabetes (T2DM) enrolling at least 200 patient*year.

RESULTS

Out of 169 patient groups in RCTs with results available for analysis, the overall proportion of patients reaching HbA1c ≤ 7 % was 36.6 (34.1-39.1) %. Of these, 8 groups included T1DM subjects [proportion at target (PAT) 27.2 (22.7-32.3) %] and 161 T2DM patients [PAT 37.1 (34.5-39.7) %]. In patients with T2DM on oral agents, at multivariate analysis, higher success rate was associated with higher age and body mass index (BMI), lower duration of diabetes, lower proportion of Caucasians and more recent publication year. Among the insulin treated, only duration of diabetes retained a significant association with success rate. Among 41 groups from cross-sectional studies, 6 and 22 were composed of patients with T1DM and T2DM, respectively, and the remaining 13 included both types. Patients at target for HbA1c were 19.8 (12.4-30.1), 36.1 (31.5-41.0), and 39.0 (32.9-45.3) %, respectively. Higher age, lower BMI, shorter duration of diabetes and a higher proportion of males and Caucasians were associated with a higher success rate.

CONCLUSIONS

Available data show that a wide distance remains between recommended targets and actual achievements in routine clinical practice.

Patient autonomy in chronic care: solving a paradox

The application of the principle of autonomy, which is considered a cornerstone of contemporary bioethics, is sometimes in obvious contradiction with the principle of beneficence. Indeed, it may happen in chronic care that the preferences of the health care provider (HCP), who is largely focused on the prevention of long term complications of diseases, differ from those, more present oriented, preferences of the patient. The aims of this narrative review are as follows: 1) to show that the exercise of autonomy by the patient is not always possible; 2) where the latter is not possible, to examine how, in the context of the autonomy principle, someone (a HCP) can decide what is good (a treatment) for someone else (a patient) without falling into paternalism. Actually this analysis leads to a paradox: not only is the principle of beneficence sometimes conflicting with the principle of autonomy, but physician's beneficence may enter into conflict with the mere respect of the patient; and 3) to propose a solution to this paradox by revisiting the very concepts of the autonomous person, patient education, and trust in the patient-physician relationship: this article provides an ethical definition of patient education.

A Qualitative Study of Patient Perspectives about Hypertension

To understand hypertensive patients' perspectives regarding blood pressure and hypertension treatment, this qualitative study applied semistructured interviews of hypertensive patients. Participants were recruited from two hypertension clinics at the University of Alberta in Edmonton, Canada. To be eligible for inclusion, patients had to be aged 18 years or older, diagnosed with hypertension by a healthcare provider, and currently taking an antihypertensive medication. Participants were stratified in the analysis according to blood pressure control. Twenty-six patients (mean age 57; 62% female) were interviewed, of which 42% were on target and 58% were not. Three underlying themes emerged from the interviews: (a) knowledge of blood pressure relating to diagnosis and management and control of hypertension, (b) integration of hypertension management into daily routine, and (c) feelings and beliefs of wellness. None of the above themes were associated with better control. Knowledge gaps were found, which emphasize the need for further patient education and physician training. Feelings and beliefs of wellness, and not knowledge, were important factors in home assessment of blood pressure. The absence of connections between control of hypertension and the identified domains indicates that current approaches could benefit from the development of a more personalized approach for education and communication.

Determinants and consequences of insulin initiation for type 2 diabetes in France: analysis of the National Health and Wellness Survey

BACKGROUND

The aim of the study was to identify the intrinsic patient characteristics and extrinsic environmental factors predicting prescription and use and, more specifically, early initiation (up to 5 years of disease duration) of insulin for type 2 diabetes in France. A secondary objective was to evaluate the impact of insulin therapy on mental and physical quality of life and patient adherence.

METHODS

The data used in this study were derived from the 2008, 2010, and 2011 France National Health and Wellness Survey. This survey is an annual, cross-sectional, self-administered, Internet-based questionnaire among a nationwide representative sample of adults (aged 18 years or older). Of the total of 45,958 persons recruited in France, 1,933 respondents (deduped) were identified as diagnosed with type 2 diabetes. All unique respondents from the three waves, currently using insulin or oral bitherapy or tritherapy at the time of assessment, were included in this analysis.

RESULTS

Early (versus late) initiation of insulin therapy was 9.9 times more likely to be prescribed by an endocrinologist or diabetologist than by a primary care physician (P < 0.0001). Younger age at diagnosis and current smoking habits were significant predictors of early (versus late) insulin initiation (odds ratio [OR] 1.031, 95% confidence interval [CI] 1.005-1.059, P = 0.0196, and OR 2.537, 95% CI 1.165-5.524, P = 0.0191, respectively). Patients with a yearly income ≥€50,000 were less likely to be put on insulin early (P = 0.0399). A link between insulin prescription and complications was shown only in univariate analysis. Mental quality of life was lower in patients on early (versus late) insulin, but only in patients with diabetes-related complications. Insulin users (versus oral bitherapy or tritherapy users) had 3.0 times greater odds of being adherent than uncontrolled oral bitherapy or tritherapy users (OR 2.983, 95% CI 1.37-6.495, P = 0.0059).

CONCLUSION

This study confirms the role of specialists in early initiation of insulin, and the data presented herein reflect the fact that early initiation is more frequent in younger patients, patients with diabetes-related complications, and current smokers, and less frequent in patients with a higher income. Moreover, we observed that being treated with insulin was not associated with deterioration in quality of life, and insulin-treated patients were more often adherent than uncontrolled oral bitherapy or tritherapy users. These data suggest that doctors' concerns about patient adherence and detrimental effects on quality of life should not be a barrier to their decision regarding early initiation of insulin therapy. Due to the nature of this cross-sectional survey (eg, inability to assess treatment flow), further research is needed to confirm its findings.

A psychophysical account of patient non-adherence to medical prescriptions. The case of insulin dose adjustment

AIM

Diabetic patients often do not adjust their insulin doses using the algorithms that they have been taught. While this behavior may intuitively have a number of causes, such as the complexity of the decision or the fear of hypoglycaemia, we propose in this article a more general, "psychophysical", explanation based on behavioral economics concepts used to describe decisions made under uncertainty and risk. The concepts discussed herein may not be familiar to clinicians, who will find here an introduction to theories that may be helpful in understanding some aspects of non-adherence to medical prescriptions.

RESULTS

1) The Prospect Theory of Kahneman and Tversky proposes that choices made in the context of risk are subject to loss aversion. 2) Decisions under uncertainty use mental short cuts called "heuristics", which can lead to biases; for instance, overestimating the probability of the risk. 3) To understand the very concept of risk, emotions must be considered with a special focus on anticipated regret. 4) Finally, selection difficulty is an important determinant of the preference for the status quo.

CONCLUSION

These concepts may be relevant for understanding a preference for the status quo in decisions made in a context of uncertainty and risk, such as insulin dose adjustment. We suggest that these mental mechanisms may also be involved in other aspects of patients' non-adherence. As other common human behaviors, non-adherence may actually often be a consequence of biases resulting from our ways of thinking, being both cognitive and emotional, and, according to Kahneman, more often "fast" than "slow". Empirical studies are needed to support this hypothesis.

Two character traits associated with adherence to long term therapies

Adherence is defined as the adequacy between the behaviours of patients and their medical prescriptions. Adherence is a general behaviour, which can explain why patients in the placebo arm of randomised clinical trials have a lower mortality rate when they are adherent. We propose that this behaviour is related to two character traits: patience (capacity to give priority to the future) and, more provocatively, obedience. To support this claim, we bring arguments from the literature and from two published personal studies. We previously showed that type 2 diabetic patients who respond as non-adherers to a questionnaire on adherence to medication and to whom one proposes a fictitious monetary choice between receiving 500 euros today or waiting one year to receive 1500 euros never make the remote choice. We also showed that obese diabetic patients who declare that they do not fasten their seat belt when they are seated in the rear of a car are more often non-adherent concerning medication than those patients who claim that they follow this road safety recommendation. Thus, one of the roles of empowerment and patient education could be to encourage the patients, if they wish it, to replace passive adherence behaviours with conscious active choices.