Transcript Adherence
Adherence in Pediatric
Psychology
Melissa Stern
November 21, 2006
What is adherence?
“the extent to which a person’s behavior
(in terms of taking medications, following
diets, or executing life style changes)
coincides with medical or health advice”
(Haynes, 1979, pp 2-3)
“a person’s behavior in relation to a
prescribed medical regimen”
(La Greca & Bearman, 2003)
Evolution of terminology
COMPLIANCE
SELF-MANAGEMENT
ADHERENCE
CONCORDANCE
Theories of Adherence
The Adherence/Compliance Approach
Applies to patients with an existing problem
Assumptions:
• Pt. needs to be treated
• Pt. wants to initiate/maintain treatment and has
sought medical care for that purpose
• Pt. should be motivated to comply for symptom
relief
Limitations: asymptomatic conditions,
overlooks barriers
Theories of Adherence
Transtheoretical Model (Stages of Change)
Five stages in the adoption of health-related
behaviors:
•
•
•
•
•
Precontemplation
Contemplation
Preparation
Action
Maintenance
Match intervention to stage
Very difficult to apply to pediatric conditions!
Theories of Adherence
Health Belief Model
Can be applied to preventative treatments
Views patients as autonomous “decision
makers”
Considers the patient’s perceptions of:
• Threat of illness
• Effectiveness of treatment
• Barriers to treatment
Again, difficult to apply to pediatric
conditions!
Measuring Adherence
Categorical approach with adherence
as a unitary construct
• adherent, nonadherent, or good,
moderate, poor
Multidimensional, continuous
construct
• Use multiple behaviors as indicators
• Assess adherence along a continuum
Why is it important to
measure adherence?
For life-threatening illnesses (posttransplant regimen)?
For chronic illnesses (asthma,
diabetes)?
For acute illnesses (bacterial
infection)?
For lifestyle medical issues (obesity)?
Measuring Adherence
Self-reports
Easy and inexpensive but have questionable
accuracy, social desirability effects, and parent/child
disagreement
Health Provider ratings
Easy and provider has extensive knowledge about
regimen but can be biased by history, health status,
patient’s presentation
Behavioral monitoring
Can be more accurate than retrospective report but
time intensive and susceptible to social desirability
Pill counts
May overestimate adherence
Medicine bottle cap removal counts
May overestimate adherence
Daily blood draws to test levels
Extremely accurate, but highly unrealistic!!
Measuring Adherence
Electronic monitoring devices
• MEMS caps, blood glucose monitors,
vests for CF
Lab assays
• blood, urine, etc. tests
• used mainly for medication adherence
Health status indicators
• biological measures of disease status
• pulmonary function tests, HgbA1c
Health Status & Adherence
Health status and adherence are not
interchangeable terms
Health status measures are widely
used by medical providers because
they have been linked to long-term
outcomes of morbidity and mortality
Most medical providers (and
psychologists, too!) infer than health
status = adherence
Health Status & Heath Behavior
Health Status
Good
Poor
Good
Behavior
Poor
Johnson, 1994
Health Status & Heath Behavior:
Pediatric Diabetes
Health Status:
Metabolic Control
Good
Poor
(HgbA1c < 7.7)
Good
Behavior:
(HgbA1c > 10.1)
30 %
18 %
24 %
28 %
Adherence
Poor
Johnson, 1994
Why the discrepancy??
Imperfect measurement of adherence
• e.g., poor measures, patients may report good
adherence but may not be performing behaviors
accurately
Treatment effectiveness can affect the
health status-adherence relationship
Chemo/radiation for a 10 y/o with leukemia
Adults taking glucosamine chondroitin for
arthritis
Health Status & Adherence:
Importance of Tx Effectiveness
Strong Tx
Good
Health Status
Weak Tx
Poor
Inert Tx
Poor
Good
Adherence
Nonadherence:
The norm rather than the exception
“ . . . patients do not fail to comply, rather, they
choose another course of behavior. The
doctor’s advice is just one input among many in
how to handle health and illness. Providers
may consider the decisions that patients make
irrational, but they may be quite rational from
the patients’ perspective.”
(Bauman, 2004)
10,000 journal articles on adherence—yet,
rates of nonadherence remain high
“adaptive noncompliance” (La Greca & Bearman, 2003)
Prevalence of Nonadherence
Nonadherence occurs regardless of age,
race, gender, and disease
In pediatric populations, nonadherence is
estimated at 50%
Rates are higher for chronic conditions
Adherence declines over time
Adolescents are generally less adherent
than younger children
Types of Nonadherence
Volitional nonadherence —patient
hears and understands the medical
advice, but chooses not to adhere
Inadvertent nonadherence —patient
accepts medical advice and believes
that they are following it
• “Good enough” adherence
• Barriers to adherence
• Misunderstood treatment regimen
Risk Factors for Volitional
Nonadherence
1.
2.
3.
4.
5.
6.
7.
Difficulty & disruptiveness of regimen
Skepticism about efficacy
Side effects
Patient beliefs, fears, concerns
Cost of treatment
Denial of diagnosis
Physician prescribing practices
Risk Factors for Inadvertent
Nonadherence
1.
Patient characteristics
Intellectual functioning, memory, stress, lack
of resources, lack of social support, disease
knowledge
2.
Developmental considerations
Medication refusal
Cognitive abilities of children
Adolescents’ independence/autonomy
Risk Factors for Inadvertent
Nonadherence
3. Provider/System characteristics
•
•
•
4.
Poor patient-provider communication
Lack of patient education
Long waiting times, geographic
distance, unfriendly staff
Regimen characteristics
•
•
Complexity
Frequency of regimen-drift over time
Special Considerations for
Pediatric Patients
Barriers can exist for the parent and the
child
Importance of family interactions
Developmental issues:
• Toddlers—may be oppositional with painful
procedures, bad tasting meds, activity restrictions
• School-aged—may not adhere if they are teased
at school
• Adolescents—may experiment with meds to exert
control, struggle for independence from parents
Special Considerations for
Pediatric Patients
Disagreements between parent/child report of
adherence
Child behavior/psychological diagnoses may be a
significant barrier
Environment in which adherence behavior needs to
occur (e.g., at school)
Disease knowledge is important for family member
who is responsible for treatment
Transfer of responsibility for disease management
from child to parent
• When should this occur?
Adherence & Self-Care
Autonomy in Diabetes
Calculated self-care index based on ratio of
self-care autonomy and psychological maturity
(cognitive function, academic achievement,
social-cognitive development)
Youth were grouped into 3 categories:
constrained, maximal, and excessive autonomy
Those with excessive autonomy had poorer
adherence (and poorer metabolic control and
disease knowledge)
Suggests that parents should remain involved
in adolescents’ self-management
Adherence Interventions
Types of interventions:
Educational approaches
Behavioral approaches
•
•
•
•
Medical supervision/monitoring
Visual cues and reminders
Self-monitoring
Reinforcement
Family Interventions
Adherence Interventions
Peer interventions
Barrier reduction?
Multicomponent interventions
“Self Management Training”