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‘Explanatory Models’ (EMs) are frameworks through which individuals and groups understand diseases, are influenced by cultural and religious perceptions of health and illness, and influence both physicians and patients’ behaviors.
To examine the role of EMs of illness (cancer-related perceptions) in physicians’ and laywomen’s behaviors (decision to recommend undergoing regular mammography, adhering to mammography) in the context of a traditional-religious society, that is, the Arab society in Israel.
Two combined samples were drawn: a representative sample of 146 Arab physicians who serve the Arab population and a sample composed of 290 Arab women, aged 50–70 years, representative of the main Arab groups residing in the north and center of Israel (Muslims, Christians) were each randomly sampled (cluster sampling). All respondents completed a closed-ended questionnaire.
Women held more cultural cancer-related beliefs and fatalistic beliefs than physicians. Physicians attributed more access barriers to screening as well as fear of radiation to women patients and lower social barriers to screening, compared with the women’s community sample. Higher fatalistic beliefs among women hindered the probability of adherence to mammography; physicians with higher fatalistic beliefs were less likely to recommend mammography.
The role of cultural perceptions needs to be particularly emphasized. In addition to understanding the patients’ perceptions of illness, physicians must also reflect on the social, cultural, and psychological factors that shape their decision to recommend undergoing regular mammography.
Predictors of compliance with aspirin in children following cardiac catheterisation have not been identified. The aim of this study is to identify the caregivers’ knowledge, compliance with aspirin medication, and predictors of compliance with aspirin in children with Congenital Heart Disease (CHD) post-percutaneous transcatheter occlusion.
A cross-sectional explorative design was adopted using a self-administered questionnaire and conducted between May 2017 and May 2018. Recruited were 220 caregivers of children with CHD post-percutaneous transcatheter occlusion. Questionnaires included child and caregivers’ characteristics, a self-designed and tested knowledge about aspirin scale (scoring scale 0–2), and the 8-item Morisky Medication Adherence Scale (scoring scale 0–8). Data were analysed using multivariate binary logistic regression analysis to identify predictors of compliance with aspirin.
Of the 220 eligible children and caregivers, 210 (95.5%) responded and 209 surveys were included in the analysis. The mean score of knowledge was 7.25 (standard deviation 2.27). The mean score of compliance was 5.65 (standard deviation 1.36). Child’s age, length of aspirin use, health insurance policies, relationship to child, monthly income, and knowledge about aspirin of caregivers were independent predictors of compliance with aspirin (p < 0.05).
Caregivers of children with CHD had an adequate level of knowledge about aspirin. Compliance to aspirin medication reported by caregivers was low. Predictors of medium to high compliance with aspirin were related to the child’s age and socio-economic reasons. Further studies are needed to identify effective strategies to improve knowledge, compliance with medication, and long-term outcomes of children with CHD.
The current study aimed to understand how moderate and severe food-insecure people living with HIV (PLHIV) in the Dominican Republic perceive a healthy diet and explore facilitators and barriers to engaging in healthy dietary behaviours as a means of HIV self-management.
We conducted semi-structured interviews with PLHIV. We generated codes on food insecurity among PLHIV and used content analysis to organise codes for constant comparison between and within participants.
Two urban HIV clinics in the Dominican Republic.
Thirty-two PLHIV participated in the interviews.
Factors that contributed to dietary behaviours include individual factors, such as knowledge of nutrition, views and attitudes on healthy dietary behaviours, beliefs about dietary needs for PLHIV and diet functionality. Interpersonal factors, including assistance from family and peers in providing food or funds, were deemed critical along with community and organisational factors, such as food assistance from HIV clinics, accessibility to a variety of food store types and the availability of diverse food options at food stores. Policy-level factors that influenced dietary behaviours were contingent on respondents’ participation in the labour market (i.e. whether they were employed) and consistent access to government assistance. Food insecurity influenced these factors through unpredictability and a lack of control.
PLHIV who experience food insecurity face various barriers to engaging in healthy dietary behaviours. Their diets are influenced at multiple levels of influence ranging from individual to structural, requiring multi-level interventions that can address these factors concurrently.
The aim of the study was to identify components of the COM-B (capability, opportunity, motivation and behaviour) model that influences behaviour to modify dietary patterns in 40–55-year-olds living in the UK, in order to influence the risk of cognitive decline in later life.
This is a qualitative study using the COM-B model and theoretical domains framework (TDF) to explore beliefs to adopting the Mediterranean-DASH Intervention for Neurodegenerative delay (MIND) diet.
Twenty-five participants were recruited onto the study to take part in either a focus group or an interview. Participants were men and women aged between 40 and 55 years. Participants were recruited via email, Facebook and face to face.
Content analysis revealed that the main perceived barriers to the adoption of the MIND diet were time, work environment, taste preference and convenience. The main perceived facilitators reported were improved health, memory, planning and organisation, and access to good quality food.
This study provides insight into the personal, social and environmental factors that participants report as barriers and facilitators to the adoption of the MIND diet among middle-aged adults living in the UK. More barriers to healthy dietary change were found than facilitators. Future interventions that increase capability, opportunity and motivation may be beneficial. The results from this study will be used to design a behaviour change intervention using the subsequent steps from the Behaviour Change Wheel.
Adherence to medication is essential for achieving good outcomes for patients with bipolar affective disorder. This study tested whether treatment and illness beliefs are important predictors of adherence to medication. Results indicate that beliefs are predictive, and may be a suitable target for modification in efforts to change behaviour.
The purpose of the present study has been to assess the societal cost of major depression and the distribution into different cost components. The impact of adherence and treatment response was also explored.
Data were collected from a randomized controlled trial of patients with major depressive disorder who were treated in a naturalistic primary care setting. Resource use and quality of life were followed during the two-year trial.
The mean total cost per patient during two years was KSEK 363 (EUR 38 953). Indirect costs were the most important component (87%), whereas the cost of drugs was minor (4.5%). No significant differences in costs or quality of life between treatment arms or between adherent and non-adherent patients were demonstrated. However, treatment responders had 39% lower total costs per patient and experienced a larger increase in quality of life compared to non-responders.
Major depression has high costs for society, primarily due to indirect costs. Treatment responders have considerably lower costs per patient and higher quality of life than non-responders. This indicates that measures to increase response rates are also important from an economic perspective.
(1) determine which antipsychotic side effects (SE) schizophrenic patients consider the most distressing during treatment with typical antipsychotics, (2) measure the impact of actual and past SE on patients' attitude toward antipsychotics and (3) assess the influence of both on adherence.
The 213 schizophrenics, treated with conventional antipsychotics, were recruited in two psychiatric hospitals in Hamburg. Subjects were assessed about type and severity of present and past side effects and their attitude and adherence to antipsychotic treatment.
The 82 (39%) patients presented present SE while 131 (61%) did not. Sexual dysfunctions (P<0.001), extrapyramidal (P<0.05) and psychic side effects (P<0.05) were rated as significantly subjectively more distressing than sedation or vegetative side effects. Patients presenting with present SE compared with patients without present SE had a significantly more negative general attitude toward antipsychotics (P<0.05), were more doubtful about their efficacy (P<0.01) and were less likely to encourage a relative to take such a medication in case of need (P<0.001). A regression analysis indicated that nonadherence was mainly influenced by negative general and efficacy attitudes toward antipsychotics and the experience of past or present antipsychotic side effects.
All antipsychotic side effects, present or past, can have a durable negative impact on patient's attitude toward antipsychotic treatment and adherence. Non-adherence is mainly determined, among other factors, by these negative attitudes, which are partly influenced by the experience of past or present antipsychotic-induced side effects.
Objective. To identify clinically useful predictors of adherence to medication among persons with schizophrenia. Method. We evaluated levels of compliance with neuroleptic medication among 32 consecutive admissions with DSM-III-R schizophrenia from a geographically defined catchment area using a compliance interview. We also assessed symptomatology, insight, neurological status and memory. Results. Less than 25% of consecutive admissions reported being fully compliant. Drug attitudes were the best predictor of regular compliance, symptomatology the best predictor of noncompliance, and memory the best predictor of partial compliance with neuroleptic medication. Conclusions. These data emphasise the complexity of factors that influence whether a person adheres to his medication regimen. Furthermore, they suggest that these factors may vary within the same person over time.
Nonadherence to antipsychotic medication is highly prevalent in patients with schizophrenia and has a deleterious impact on the course of the illness. This review seeks to determine the interventions that were examined in the past decade to improve adherence rates.
The literature between 2000 and 2009 was searched for randomized controlled trials which compared a psychosocial intervention with another intervention or with treatment as usual in patients with schizophrenia.
Fifteen studies were identified, with a large heterogeneity in design, adherence measures and outcome variables. Interventions that offered more sessions during a longer period of time, and especially those with a continuous focus on adherence, seem most likely to be successful, as well as pragmatic interventions that focus on attention and memory problems. The positive effects of adapted forms of Motivational Interviewing found in earlier studies, such as compliance therapy, have not been confirmed.
Nonadherence remains a challenging problem in schizophrenia. The heterogeneity of factors related to nonadherence calls for individually tailored approaches to promote adherence. More evidence is required to determine the effects of specific interventions.
Quality of life (QoL) is increasingly considered an important outcome in health research. We wished to explore the determinants of change in QoL in patients with schizophrenia over the course of a one-year RCT.
Predictors of change in observer-rated QoL (Quality of Life Scale: QLS) were assessed in 363 patients with schizophrenia during the CUtLASS clinical trial.
Change in QLS score over the course of a year correlated with change in psychotic and depressive symptoms and treatment adherence. Linear regression showed that improvement in QoL was predicted by reduction in negative and depressive symptoms and improvement in adherence rating. These three change scores together explained 38% of the variance in QLS change. Exploration of the direction of any possible causal effect, using TETRAD, indicated that improved adherence leads to improved QoL, and that change in depression also leads to QoL change. The relationship between QoL and negative symptoms suggests that greater social activity (reflected as better QoL scores) improves negative symptoms. Such a direct relationship between treatment adherence and QoL has not been reported before.
Improving adherence to medication would appear to be a key approach to improving measured quality of life in people with schizophrenia.
Several data suggest an association between repeated psychotic episodes in patients with schizophrenia and poor outcomes on the course of the illness, including worse psychosocial functioning and quality of life, deterioration and stigma. However, there is strong evidence showing antipsychotic efficacy for relapse prevention in chronic and first-episode patients. Non-adherence and partial adherence to antipsychotic treatment is a common feature that has been detected in half or more patients with schizophrenia. The use of long-acting injectable antipsychotics (LAIs) is a valuable treatment option in order to prevent non-adherence rates and the risk of relapse in patients with schizophrenia. Nevertheless, LAIs are an underutilized, yet efficacious, treatment option. This underutilization is due, at least in part, to patients and clinicians reluctance to use LAIs because of needle pain, time constraints, stigmatization, and cost. However, results from recent meta-analytic evidences including randomized control trials (RCTs) are in contrast with those from naturalistic cohort studies or mirror-image studies in showing superiority of LAIs versus oral antipsychotics (OAPs) in preventing relapse in patients with schizophrenia. After a review of updated data, guidance will be offered concerning the appropriate use of LAIs in patients with schizophrenia.
Adherence to a regular medication regimen may be challenging for adults with attention deficit hyperactivity disorder (ADHD). Some report taking psychostimulants on a pro re nata (PRN) basis. This review aims to establish the rate of adherence, and reasons for and consequences of non-adherence to medication for ADHD in adults, and to review literature on PRN dosing of psychostimulants in these patients. A systematic literature search was conducted. Four primary research studies have investigated the rate of adherence to medication in adults with ADHD. Mean adherence rate in two studies ranged from 52% to 87%. A number of possible reasons for poor adherence have been suggested. Prospective studies are needed to further define the rate of adherence and causes of poor adherence. Evidence examining whether differences in adherence affect clinical outcomes is equivocal. Therefore, caution should be applied to the assumption that maximising adherence to regular medication regimens will improve clinical outcomes. Two articles acknowledge that patients take medication on a PRN basis. Studies comparing the effectiveness of a regular and PRN regimen of psychostimulants are needed. If PRN dosing is as effective as a regular regimen, advantages might include enhanced doctor-patient communication, reduced side effects and cost savings.
The aim of this analysis is to describe medication adherence, and treatment persistence, in adults with attention deficit/hyperactivity disorder (ADHD) treated for 24 weeks with extended release methylphenidate (MPH-ER). Additionally, patient-, disorder- and treatment-related factors associated with adherence and persistence will be identified.
Post-hoc analysis of the active treatment group of a placebo-controlled, randomised, 24 week trial with MPH-ER with univariate description and multiple logistic regression models and Hosmer and Lemeshow tests.
In the sample of 241 adults with ADHD (mean age of 35.2 ± 10.1 years), 9.4% of the patients were non-adherent, taking less than 80% of the dispensed medication. Factors associated with non-adherence included age < 25 years, education level lower than secondary education, lacking family history of ADHD, lower ADHD baseline severity and lower self- and observer-rated medication efficacy. Lacking family history of ADHD, lower education level and lower self-rated medication efficacy, predicted non-adherence with a prediction accuracy of 16%. Seventeen percent of the patients discontinued early with most discontinuing within the first five weeks of the MPH-ER titration phase. Mean persistence in the discontinuing group was 63.4 ± 49.4 days. Factors associated with discontinuation included male gender, lower education level, lacking family history of ADHD and lower self- and observer-rated medication efficacy. Treatment non-response, male gender and lower education level predicted treatment discontinuation with a prediction accuracy of 22.7%.
Male adults without relatives with ADHD, with lower educational level and lower self- and observer-rated medication efficacy, who are newly treated with MPH-ER, are at increased risk of non-adherence and treatment discontinuation. Patients are at increased risk of treatment discontinuation during the medication titration phase.
To assess whether the combination of motivational interviewing and psychoeducation affects relapse rate and stimulates involvement of people with psychosis in their treatment. We conducted an interventional study including patients with schizophrenia or schizoaffective disorder treated with oral antipsychotics, without previous experience of long-acting injectable antipsychotics (LAIs). They were randomised to either psychoeducation with motivational interviewing or a control group. Hospital admissions 18 months before and after the intervention, and switches to LAIs 18 months after the intervention, were recorded.
The two groups each comprised 101 participants. Fourteen from the intervention group and seven from the control group switched to LAIs. Five in the intervention group instigated the switch themselves, compared with zero controls (P = 0.06). Fourteen in the intervention group were readmitted to hospital during follow-up, compared with 23 in the control group (P = 0.14).
Psychoeducation with motivational interviewing may increase patients' involvement in their treatment and reduce the relapse frequency.
Relapse rate among patients with schizophrenia can determinate outcome of illness. Up to 40% of patients with first psychosis responds well to treatment. Despite this fact relapse rate is still high, in particular if treatment is discontinuated. Frequent use of first generation antipsychotics (FGA) in underdeveloped countries can be one of possible reasons for treatment discontinuation and consequent relapse.
To analyse rehospitalisation rate in patients with first and multiple episodes of schizophrenia, and compare it with medication choice.
Retrospective analysis of medical records of patients with schizophrenia hospitalised in Psychiatry Clinic of University Clinical Center Tuzla in period from year 2011 to 2013.
During the two-year period, 37 patients with first episode of schizophrenia were hospitalised. Second generation antipsychotics (SGA) were used in 40.5%, and first generation in 13.5%, long acting injectibles - first generation (LAI) were used in 8.1%, and combination of FGA's and SGA's in 5.4% of cases. In the same period, 121 patients with multiple episodes of schizophrenia were hospitalised. SGA were used in 21.4%, FGA in 33%, LAI's in 47.1%, and combination FGA's and SGA's in 35.5% of cases. Relapse rate in the first year after discharge was 16.2% in group with first psychotic episode, and 33% in the group with multiple episodes of schizophrenia.
High relapse rate in group with multiple episodes can be explained with nonadherence regarding the side effects of too frequent use of FGA's.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Low- and middle-income countries (LMICs) experience a disproportionate burden from chronic psychotic disorders (CPDs), which are the most disabling conditions among people aged 10–24 in Sub-Saharan Africa. Poor medication adherence is seen in approximately half of individuals with CPDs in Sub-Saharan Africa, and is a major driver of relapse. A CPD treatment approach that combines the use of long-acting injectable (LAI) antipsychotic medications with a brief and practical customised adherence-enhancement behavioural intervention (CAE-L) was recently developed and tested for use in the USA.
To use a qualitative cross-sectional analysis to gather information on potentially modifiable barriers to management of CPDs, and assess attitudes about LAIs from community participants in Tanzania. Findings were intended to refine the CAE-L curriculum for use in Tanzania.
In-depth interviews and focus groups were conducted with 44 participants (patients with CPD, caregivers, mental healthcare providers). All interviews and focus groups were audiotaped, translated, transcribed and analysed using content analysis, with an emphasis on dominant themes.
Findings indicated that promoting medication adherence and management of CPDs in the Tanzanian setting needs to consider the individual with CPD, the family, the healthcare setting and the broader community context.
Qualitative findings enabled the study team to better understand the real-time barriers to medication adherence, LAI use and management of CPDs more broadly. Refinement of the CAE-L is expected to pave the way for an intervention trial for individuals with CPDs that is culturally and linguistically appropriate to the Tanzanian setting.
To identify factors influencing successful international travel among patients with psychotic illness.
Eight individuals participated in a semi-structured interview of 15–20-minute duration with a clinician in relation to their recent experience of international travel. Clinical files were reviewed and a case series was compiled.
Four individuals engaged in international travel without any adverse effects. Four other individuals experienced significant psychotic and/or affective symptoms while travelling. Treatment non-adherence, a lack of awareness of how to obtain support and limited or no pre-travel planning were noted in these individuals.
Pre-travel counselling, treatment adherence, provision of information packages relating to their mental illness and having contact details of their treating mental health team increase the likelihood of successful international travel in patients with psychotic illness. Travelling with a companion may reduce fear of relapse.
Although internet-based cognitive behaviour therapy (ICBT) is an effective treatment for social anxiety disorder (SAD), a substantial proportion of patients do not achieve clinically significant improvement. More research is needed to identify which factors predict treatment adherence and outcomes.
The aims of this study were to (1) identify demographic and clinical factors associated with treatment adherence and outcomes in ICBT for social anxiety in China, and (2) explore whether low-intensity therapist support results in improved treatment adherence or outcomes.
Participants were assigned to either therapist-guided (N = 183) or self-guided ICBT (N = 72). Level of social anxiety was measured at both pre- and post-treatment. Treatment adherence and outcomes were analysed using a two-step linear and logistic regression approach. Clinical and demographic characteristics were examined.
No significant group differences were found for treatment adherence or outcomes between the therapist-guided and self-guided conditions. Participants diagnosed with SAD were significantly less likely to drop out (OR 0.531, p = .03) compared with subclinical participants with social anxiety symptoms. Older participants (B = 0.17, SE = 0.04, p = .008) and participants with a diagnosis of SAD (B = 0.16, SE = 0.44, p = .01) tended to complete more modules. Participants who completed more modules (B = 0.24, SE = 0.03, p = .01) and participants who identified as female (B = –0.20, SE = 0.18, p = .04) reported greater reductions in SAD symptoms.
Understanding of factors related to adherence and outcome is necessary to prevent drop-out and optimize outcome.
To examine the contributions of two aspects of executive functioning (executive cognitive functions and behavioral control) to changes in diabetes management across emerging adulthood.
Two hundred and forty-seven high school seniors with type 1 diabetes were assessed at baseline and followed up for 3 years. The baseline assessment battery included performance-based measures of executive cognitive functions, behavioral control, IQ estimate (IQ-est), and psychomotor speed; self-report of adherence to diabetes regimen; and glycated hemoglobin (HbA1c) assay kits as a reflection of glycemic control.
Linear and quadratic growth curve models were used to simultaneously examine baseline performance on four cognitive variables (executive cognitive functions, behavioral control, IQ, and psychomotor speed) as predictors of indices of diabetes management (HbA1c and adherence) across four time points. Additionally, general linear regressions examined relative contributions of each cognitive variable at individual time points. The results showed that higher behavioral control at baseline was related to lower (better) HbA1c levels across all four time points. In contrast, executive cognitive functions at baseline were related to HbA1c trajectories, accounting for increasingly more HbA1c variance over time with increasing transition to independence. IQ-est was not related to HbA1c levels or changes over time, but accounted instead for HbA1c variance at baseline (while teens were still living at home), above and beyond all other variables. Cognition was unrelated to adherence.
Different aspects of cognition play a different role in diabetes management at different time points during emerging adulthood years.