Adherence: transforming cure into care


Within the field of medical adherence, we become equipped with the phrases to explain the importance of what we do. We learn the chorus: approximately 50% of patients do not take medicines they are meant to; communication barriers between clinicians and patients can leave adherence unaddressed; poor adherence leads to increased morbidity and mortality. Swimming in p values and questionnaires and segmentation, it is sometimes easy to forget the worth of empowering patients by investigating non-adherence to our patients.

The need for patient empowerment is echoed throughout healthcare and we know that involving patients in conversations about adherence is part of this. Many of the constructs that define patient empowerment, such as personal control and self-efficacy, are synonymous with the theories behind Spoonful of Sugar (SoS) frameworks that measure and understand adherence. If knowledge is power, then our frameworks enable us shape adherence programmes in a way that responds to and gives weight to our patients’ needs and values. But what worth does this hold for patients?

By listening to what patients think about their medication regime, we add value to how patients feel, and appreciate how complicated this can be. As someone whose medical files are laced with finger-tip-unit-only steroids, count-to-five-between-puffs inhalers, and “I nag because I care” relatives, it is comforting to know that adherence studies humanise us. Our researchers remove the fear of stigmatising labels such as “lazy”, “ignorant” and “ungrateful” by understanding the complexity of behaviour. Our approach breaks down the “them” and “us” wall between healthcare professionals and patients. We encourage empathetic care and create opportunities to share repressed worries and frustrations. Our knowledge of adherence does empower patients, but ultimately, we ensure cure is transformed into care.

There is no p value to measure the relief we feel when we can voice our thoughts on our treatment, but the significance of being understood cannot be over stated.


Empowering patients: Better Health Outcomes through Adherence


In a previous blog we introduced the concept of the 4-state Necessity beliefs and Concerns Framework (NCF)™ map as a way of “visualising” patients’ likelihood to adhere to their treatment. Using the same NCF, this time we are focusing on patient’s treatment-related empowerment as a driver for adherence, i.e., does a patient being empowered affect their motivation to adhere to medication to manage their long-term conditions, as shown through their location in the NCF.

Recently, Patient Centricity has become a mantra in Health – from policy makers to industry and patient’s associations to healthcare stakeholders, all claim that empowering patients to take more control on their treatment leads to better health outcomes. Makes sense, now let’s show one way empowerment creates a direct route to improved health outcomes through better adherence.

Our recent studies based on patient’s self-reported empowerment, using the Treatment-related Empowerment Scale (TES)™ and their Necessity beliefs and Concerns,were measured using the Beliefs about Medication Questionnaire (BMQ)™. This showed there is an important correlation between these concepts; superior empowerment of patients with long-term conditions helps them have an Accepting attitude towards their medications.

Interestingly this approach can be a building block to provide a valuable estimate of how much increasing empowerment increases adherence. By way of example, the below table provides an estimated average adherence to treatment for patients with Type 2 Diabetes Mellitus according to their “location” on the 4-state NCF map following assessment of their perceptions of their medication.

Using the above data and large dataset correlating TES™ and BMQ™, we can infer an almost 9% to 10% increase in adherence to treatment in the more highly empowered patients compared to those poorly empowered.

Want to know more? Give us a call. We’ll be delighted to help you.

1 Mann, D., Ponieman, D., Leventhal, H., & Halm, E. (2009). Predictors of adherence to diabetes medications: the role of disease and medication beliefs. Journal of Behavioral Medicine, 32(3), 278-284.


How predictable could patient’s adherence to treatment be?


Patients taking medications to manage their long-term conditions show different attitudes over time. We have demonstrated time and again that patient’s motivations to adhere to their treatment obey to their necessity beliefs and concerns regarding their medication and those beliefs drive their behaviours. The fact that these behavioural drivers exist means that behavioural changes following an intervention on a cohort leads to changes on the overall adherence. Obvious!… but is it predictable?

 

 

The Necessity beliefs and Concerns Framework (NCF™) has a two-dimensional spatial representation for mapping patient’s location into 4 quadrants each one representing one of 4-states [Sceptical (low Necessity beliefs, high Concerns), Ambivalent (high, high), Indifferent (low, low), Accepting (high, low)] based on their answers to the Beliefs about Medication Questionnaire (BMQ™). This is certainly not a static situation over time and it is at the core of SoS behavioural change methodology to create informed patients, so their choice guide their “movements” across the 4-states NCF™ map. Why? Because patients’ adherence to their treatment is strongly dependant on their psychological state… and there is obviously an ideal state [Accepting] where their necessity beliefs are high and have low concerns about their medication which leads to superior adherence levels, which improves their health. This does not mean that patients in the other 3 states are not adherent at all, but it is so much simpler to achieve the highest levels of adherence no matter the disease area when patients are in this Accepting state (for instance, 6 times more for patients with type 2 diabetes mellitus) that it worth all necessary efforts and costs from healthcare stakeholders.

 

Remember: no patient’s location in the 4-state NCF™ map is eternal, so the good thing is that we can design interventions to change patient’s behaviour to help them become more adherent, and the bad thing is that there are counteracting external forces that negatively impact on their motivations to “move”. Patients conscious and unconscious choices lead to “movement” across the 4-state NCF™ map. Understanding patients’ intrinsic and extrinsic motivations through the Perceptions and Practicalities Approach (PAPA™) is key to laying the pathway for change and proceeding with bespoke patients’ behavioural change programme is an integral part of any Patient Support Programme.

 

For those of you who think “the shortest distance between 2 points is the straight line” … Yep! This is not always evident, at least in the 4-state NCF™ map for those Sceptical patients who face a dilemma: can they both reverse their low Necessity beliefs and high Concerns at the same time? Possible but difficult. Transitions tend to occur sequentially so it is likely patients “move” from a Sceptical state to an intermediate state [Ambivalent, Indifferent] through behavioural change programmes rather than “jumping” directly towards the Accepting state.

 

And here is your food for thought: Which is the optimum pathway to acceptance, is it more difficult to first raise a patients’ low Necessity beliefs or lowering their high Concerns. And a related thought: Should you aim to first “move” those patients in an Indifferent state towards the Accepting state by heighten their Necessity beliefs or transforming Ambivalent patients into Accepting patients by lowering their Concerns. If these questions are bothering you, as you look to create optimally effective Patient Support Programme, then we look forward to hearing from you.