Relationship between selfefficacy and compliance

1
Relationship between self-efficacy and compliance

• Hanne Herborg
• Director RD
• Pharmakon

2
Task and plan

• Task
• Explore the tension between the concepts
• Compliance
• Self-efficacy
• Concordance
• Pharmaceutical Care
• Discuss implications for research and practice
• Plan
• Personal reflections on
• Research challenges
• The problem and the concepts
• Measuring issues
• Practice implications

3
The relevance for pharmaceutical care research

• Should the new models be integrated more
  explicitly in next generation pharmaceutical care
  projects?
• Do the new models compete with, replace or
  supplement pharmaceutical care?

4
Pharmaceutical care research - next generation
challenges

• Interventions
• Interventions are too weak in terms of competence
  in coaching for behaviour change
• Complex interventions have worked, but also been
  time consuming and not realistic?
• Can we construct brief, but complex,
  interventions?
• Conceptual issues
• Do we understand the nature of peoples medicine
  taking and the psycho-social mechanisms we can
  work with in pharm. care
• New constructs are not well integrated in the
  models
• Does new consumerism add new dimensions to the
  problem?

5
Pharmaceutical care research - next generation
challenges

• Measurement
• Intervention studies have poor compliance data
  not showing the real changes
• Other behavioural changes are not documented in
  the same extent as compliance
• Can we measure adherence to a concordance
  contract?
• Should we rather measure self-efficacy?

6
The nature of the problem- Taking medicines is a
behaviour integrated in everyday life

• A systems approach is required, not just patient
  factors as in most compliance research
• Environment factors
• Health system factors
• Treatment, disease
• Support network, professionals
• Patients social context
• In this talk I concentrate on the patient factor!
  
• Aspects Motivational, emotional, cognitive,
  behavioural

7
Pharmaceutical care- a strong model with a
systems approach

• Continuous quality improvement function for drug
  therapy
• Monitoring the medication-use-process as a system
  rather than working with isolated process factors
  and blaming individuals
• Focussed on outcomes
• QOL health and well-being
• Treatment failure
• Adverse effects
• Aim To prevent drug-related morbidity and
  mortality
• A collaborative responsibility involving all
  health professionals and patients in the drug-use
  system
• Hepler and Grainger Rousseau 2000

8
Definitions

• Compliance
• The extent to which patients follow instructions
  for prescribed treatments
• Concordance
• An agreement reached after negotiation between a
  patient and a health care professional that
  respects the beliefs and wishes of the patient in
  determining whether and how medicines are to be
  taken.
• Although reciprocal, this is an alliance in which
  the health care professionals recognise the
  primacy of the patients decisions about taking
  the recommended medicines

9
From compliance to concordance

• A historical perspective on the shift
• Evidence-based medicine
• Shift from seeing compliance as an end in itself
• Concordance key elements
• Patient as ultimate decision maker
• Patient perspectives, autonomy and empowerment
• Partnership Mutual agendas respected
• An ethical conflict
• Authoritarian vs collaborative values
• Expert power vs consumer power
• A conflict between research paradigms
• A medico-centred, technical, functionalist
  tradition
• A radical, humanistic, empowerment tradition

10
Determinants of non-compliance- confusing
evidence

• Strong influence
• Complex dose regimes
• Physical, mental and social vulnerability
• Failures of physician/patient communication
• Weak influence
• Demographic differences age, sex, social class
• Clinical variables Symptoms, diseases, classes
  of drugs, regimens
• General trend
• The models have poor explanatory power
• RPSGB 1997

11
Significant non-compliance patient beliefs-
non-concordance is common

• Perceived efficacy of the medicine
• The danger of becoming immune over time
• The unnaturalness of manufactured medicines
• The danger of addiction and dependence
• An anti-drug attitude
• Balancing risks and benefits
• Discrepancies between the doctors and the
  patients perceptions of risk
• Managing everyday life (practical barriers, pill
  burden..)
• Britten 1996

12
Non-compliance- is multidimensional

• Categories
• Intentional
• Unintentional
• Stages of adherence
• Acceptance to begin treatment
• Execution of treatment plan
• Continuation of treatment (persistence)
• Once accepted problems are often pragmatic
  rather than motivational
• Urquhart 1999

13
Self perceived use of medicines- Angina
Pectoris A story of irrationality?

• Categories found in qualitative interviews by
  pharmacy students
• (N 123 patients)
• Active self regulation 25
• Forgetfulness 50
• Compliance 71
• Selozok makes me very tired, its so annoying.
  It would really disrupt my daily life if I were
  told I have to take a whole tablet every day
  half a tablet is bad enough. Ive tried that. So
  Ive juggled around a bit. Maybe Ill have to
  start taking a whole tablet because I still have
  a few symptoms. I worry about everything I have
  to do and it annoys me that I do not have the
  energy to do it
• Woman, age 78
• Haugbølle, Sørensen Herborg, 2002

14
An inadequate model- combining quantitative and
qualitative research

• Non-compliance is not a a technical phenomenon or
  a simple, linear problem based in lack of
  knowledge or forgetfulness
• Medication use is a complex set of behaviours
  rooted in the social context of everyday life of
  the medicine user and in the skills, values and
  health beliefs held by the user
• Conflicting beliefs and behaviours may co-exist
  and vary between individuals and within the same
  person depending on situational factors
• Compliance is a continuous, dynamic, situational,
  interactional, behavioural phenomenon
• Non-compliance exists in all cultural, social and
  clinical contexts, but has culture, disease and
  technology specific dynamics

15
Is concordance a stronger model?

• We dont know!
• Weak evidence for effect on outcomes for
  patient-centred consultations
• Mainly impact on satisfaction
• (Mead Bower 2002)
• Strengths
• Ethically stronger
• Deals with user perspective and preferences
• Complexity can be captured
• Can address new consumer roles
• Weaknesses
• Is it implemented?
• Always relevant?
• Adherence criteria more complex
• Does not focus on support for behaviour change

16
Concordance- a new model for patient
relationships, not an alternative to compliance

• Implementation of drug therapy
• Still a key issue
• Changed agenda
• Are agreed plans implemented?
• Are goals reached?
• Adherence is the better term?
• Consequence concordance has not replaced
  compliance

17
The serious consequences of not implemented
therapy remain the same

• Drug treatment failure
• Non-response or non-adherence unknown
• Unnecessary change and addition of treatment
• Adding drug costs and adverse effects
• Sudden adherence risk of toxicity
• Risk of drug resistance (e.g. HIV, TB)
• Leading to
• Drug related morbidity and mortality
• Waste of health care resources Drugs, GP and
  nurse visits, hospitalisations
• Lost work days and earnings

18
Self-efficacy- definition

• Perceived self-efficacy refers to beliefs in
  ones capabilities to organize and execute the
  courses of action required to manage prospective
  situations
• (A.Bandura 1995)
• Self efficacy is about peoples thoughts about
  their capability to perform a certain task not
  their actions

19
Banduras social cognitive theory- Reciprocal
determinism of human agency
20
Relationship between efficacy beliefs and
outcome expectanciesBandura
Person
Outcome
Behavior

• Outcome
• expectancies
• Physical
• Social
• Self-evaluative

• Efficacy beliefs
• Level
• Strength
• Generality

21
Sources of self-efficacy - observational
learning and self-regulation

• Mastery experience
• Vicarious experience
• Social persuasions
• Physiological and emotional states

22
Evidence

• Qualitative example
• Asthma patient
• Woman 60, former sales assistant in supermarket
• Attended Asthma TOM-programme in local pharmacy
• Feels much better, previously a lot of attacks
  and fear
• Knows very little about drugs and disease
• I have the book, you know. I can always look it
  up
• I know what to do
• If I dont know what to do, I just go and ask
  her at the pharmacy
• Quantitative research
• Self-efficacy is a strong predictor of
• Adherence
• Coping with disease
• Health outcomes

23
Self-efficacy or self management

• Is SE a better competence measure than knowledge?
  Yes probably.
• Does SE describe concordance? Not really
• Can SE be the main model change in medication
  taking during a pharm. care intervention? That
  depends!
• If a person is motivated/positive to taking
  medicines, SE is a powerful mechanism and
  predictor
• If the pros and cons are not at all in favour
  of taking drugs, other models are better at
  describing the change process
• We need variables to also describe the
  motivational stage
• Decision balance, self-efficacy, temptation to
  relapse
• Self-efficacy has been integrated with other
  models e.g. Stage of change, Health Belief Model
• Self-management rather than self-efficacy is a
  model that can supplement pharmaceutical care

24
Measuring
25
Implications for research- many levels

• Qualitative studies
• Quantitative studies
• Descriptive problem surveys
• Explanatory studies
• Studies of psycho-social mechanisms involved in
  change process
• Documentation of process and outcomes
• Development of tools for educational
  interventions
• Diagnostic instruments
• Instruments for patient feed-back

26
Compliance studies- Meaningful analyses?

• Categorical mismatch
• Intentional/unintentional
• Acceptance, implementation, persistence
• The situational and dynamic nature of compliance
  is usually left out
• Poor quality of therapy not reflected
• The empowered patient is the ideal in realistic
  practice
• Compliance with appropriate therapy
• Intelligent non-compliance with inappropriate
  therapy
• Relations to outcomes are often missing
• Poor validity of compliance measurements

27
Medication Adherence Scale- Medical Outcomes
Study

• I had a hard time doing what the doctor suggested
  I do
• I found it easy to do the things my doctor
  suggested I do
• I was unable to do what was necessary to follow
  my doctors treatment plans
• I followed my doctors suggestions exactly
• Generally speaking, how often during the past 4
  weeks were you able to do what the doctor told
  you
• Scale 1-5, from none of the time to all of the
  time
• Sherbourne, Hays, Ordway, DiMatteo, Kravitz 1991

28
Compliance measurement - poor reliability, lack
of detail and overestimation

• Old strategies
• Serum drug concentration
• Marker drugs
• Pill counts
• Prescription refills
• Patient medication records
• Questionnaire, patient reports
• Diaries
• GP, nurse, pharmacist interviews

• New strategies
• Automated telephone monitoring
• Electronic monitoring devices
• Clinical outcomes monitoring
• Humanistic outcomes monitoring (QOL, symptoms,
  self-efficacy)
• Solution Pragmatic triangulation

29
Transition from punctual to erraticUrquhart 2002
holiday
30
WHITE-COAT COMPLIANCE--taking the medicine just
before the scheduled visitUrquhart 2002
31
Measuring concordance and self-efficacy

• Concordance
• Difficult, important, but how?
• Patient centred process
• Accept of concordance contract
• Satisfaction with communication and autonomy
• Self-efficacy
• Several validated, reliable scales
• Clear evidence of preditive properties
• Generic vs. specific?

32
Generalized Self-Efficacy Scale- perceived
competence

• I always manage to solve difficult problems if i
  try hard enough
• If someone opposes me, I can find ways and means
  to get what I want
• It is easy for me to stick to my aims and
  accomplish my goals
• I am confident that I could deal efficiently with
  unexpected events
• Thanks to my resourcefulness, I know how to
  handle unforeseen situations
• I can solve most problems if I invest the
  necessary effort
• I remain calm when facing difficulties because I
  rely on my coping abilities
• When I am confronted with a problem, I usually
  find several solutions
• If I am in trouble, I can usually think of
  something to do
• No matter what comes my way, I can usually handle
  it
• Jerusalem Swartzer 1992

33
Long-term Medication Behavour Scale Scale
0100, 33 itemsI feel confident taking my
medication.

• Personal attributes (ex)
• when I feel very happy/sad
• when I am in pain
• when I feel very healthy/ill
• while unknown people are watching me
• when I have little trust in my GP
• Environmental factors (ex)
• during the weekend
• while at work
• when I have visitors
• while travelling
• when I am in the middle of a project at home
• when nobody reminds me

• Behavioural and task related factors
• in absence of medication aids
• when intake does not follow meals
• when pills are difficult to swallow
• when I dont see the use of it
• when I dont know what it is for
• even though it causes spots on my face and
  extensive hair growth
• even though it may give me brittle bones
• even though I may become impotent
• De Geest 1994

34
Stage of change for medication adherence- and
sub-constructs decisional balance,
self-efficacy, temptation to relapse

• No, I do not take and right now am not
  considering taking my (e.g.hypertension)
  medication as directed, (precontemplation)
• No, I do not take but right now am considering
  taking my medication as directed, (contemplation)
  
• No, I do not take but am planning to start taking
  my medication as directed, (preparation)
• Yes right now I am consistently taking my
  medication as directed,
• How long have you been taking your medication as
  directed?
• lt3months, gt3-6 months, (action)
• gt6-12months, gt12 months (maintenance)
• Willey 2000

35
Studying change to self management- a long range
of relevant psycho-social constructs

• Motivation
• Accept of concordance contract
• Desire for information
• Locus of control
• Internal, external, chance
• Attitude to drugs
• Intentions
• Outcome expectancies
• Risks, benefits
• Stage of change
• Cave Respondent burden!

•  Cognition
• Knowledge
• Perceived self-efficacy
• Perceived social support
• Sense of coherence
• Comprehensibility, manageability, meaningfulness 
• Behaviour, outcomes
• Adherence, Self-regulation
• Coping with disease
• Qol, health status
• Satisfaction

36
Implications for practice

• Practice needs models that can deal with the
  complexity of the problem

37
Patient educational preferences- rheumatoid
arthritis

• One to one basis
• Disease
• Treatment
• Emotional issues
• Group basis
• Self-management
• Exercise
• Relationship issues
• Barlow, Cullen, Rowe 2002

• Video demonstrations
• Use of aids
• How other families cope
• Leaflets and information packs
• Usefull support for all topics
• Not alone
• Adresses
• Computerbased interventions
• Not preferred

38
Evidence on compliance interventions

• General trends
• Low to moderate effect sizes regardless of health
  issue, theory base or method
• Non-compliance cannot be cured
• Simple treatment regimens gives better compliance
  - short and long term
• Several complex strategies improve compliance
• Comprehensive strategies combining affective,
  behavioural and cognitive elements are more
  effective
• Weak evidence for value of information
• Some evidence for the value of prompts, reminders
  and compliance aids
• Cochrane library and RPSGB reviews

39
Types of interventions

• Multidimensional interventions have better impact
• Dimensions
• A Affective
• Motivational and/or emotional support
• B Behavioural
• C Cognitive

40
Intervention examples- aim at concordance and
self-efficacy

• Affective strategies
• Relationships allowing discussion of
  non-adherence
• Express concern, listen to concern
• Involve network, social support
• Motivational written information
• Acceptable drug technology

• Cognitive strategies
• Patient education individual and group
• Family education
• Verbal counselling
• Written instructions
• Video demonstrations
• Computer assisted education programmes

41
Intervention examples- Behavioural strategies

• Simplified dosage
• Follow-up reminders, prompts
• Automated telephone counselling
• Refills pills scheduling tools
• Multi-dose aids
• Dose-dispensing
• Rewards
• Forgiving drugs

• Concordance contracts
• Self-monitoring, feedback systems
• Find tailored solutions to barriers
• Provide access to role-models
• Provide opportunity for mastery experience
• Improve convenience of care, e.g. workplace
  access
• Improve access to information

42
New adherence technologies- key tools for the
pharmacist

• Automated dose-dispensing
• Intelligent package devices
• Prompts via SMS or automated telephone calls
• Internet health information access
• Self monitoring via internet
• Video demonstrations
• Pharmaceutical care technology feedback
• Electronic patient medication records
• Drug alarms Interaction, dosage, double
  medication

43
Training

• Pharmacists need
• To perceive themselves as self-management
  educators
• Models that are feasible within realistic
  resources
• Tools and training in self-management

44
Pharmacy counselling about Self CareThe
Two-legged Platform

• The Scientific Leg
• Keywords
• Evidence based, quality controlled practice
• Medical starting point
• Expert role
• Objective (value neutral)
• Focus on symptoms, drug problems, and life style
  problems
• Identify risks, errors and problems
• Give correct advice and treatment
• Network gives interference and errors
• The professional is in charge

• The Humanistic Leg
• Keywords
• User competence, empowerment
• Starting point in every day life
• Discussion partner
• Personal, subjective (with values)
• Focus on the users experiences, wants,
  comprehension, habits, and terms
• Identify resources
• Help to tailor solutions
• Network are important resources
• The user is in charge

45
My conclusions- should the new models replace or
be integrated in pharm.care?

• Pharmaceutical care as a systems based concept is
  a stronger model for achieving goals in drug use
  than models working primarily with patient
  factors
• Compliance is an inadequate model. Kill it!
• Adherence should replace compliance. An
  implementation concept is necessary
• Concordance adds to pharm.care by providing a
  sharper platform for patient centred
  communication and installing the patient as the
  primary decision maker
• Perceived self-efficacy is a key measure and can
  improve effectiveness of psycho-social
  interventions in pharm. care with stronger
  mechanisms for behaviour change
• Self-management, rather than self-efficacy, is a
  comprehensive model that can integrate these
  concepts and other relevant constructs and
  provide pharm. care research with a stronger
  patient factor