[e-drug] promoting adherence (2)

e-drug
1

E-DRUG: promoting adherence (2)
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Multiple interventions for promoting adherence have certainly been shown
to be more effective that single interventions. However I have often been
surprised at attempts to promote adherence that are applied in a blanket
and non-discriminatory way. Studies say things like "intervention xyz was
not effective. But when data were adjusted for age, sex and *baseline
adherence* we showed greater improvement in adherence in the test group."
A good example of this is Friedman RH et al American Journal of
Hypertension 1996;9:285-92. Well, the obvious question is why apply an
intervention to people who were adherent at baseline ... can they benefit
from your intervention?

The next similar error (in my opinion) is, once non-adherent patients have
been identified, interventions are applied to all of them in the same
way. So, to use an example, patient information leaflets, education
sessions, support groups, DOTS or whatever are simply thrown at patients
in a blanket way. If a patient is well informed and knowledgeable but in
denial about their disease will a patient information leaflet make any
difference at all - obviously not. So, we need to make some effort at
identifying reasons/causes for non-adherence and then apply appropriate
interventions to those patients who can benefit from them.

It may be that by applying mutliple interventions we simply hit on the one
that will work for each individual by luck, in a rather resource intensive
and wasteful way. It may be that if we could identify causes of
non-adherence in non-adherent patients and apply the right intervention in
an intelligent way, that we would be more successful at lower cost.

Dr David Green
South Africa
david@on-cue.co.za
http://www.on-cue.co.za

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2

E-DRUG: promoting adherence (3)
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I am sorry my response to David Green's message of 1 April has been delayed
by other tasks.

David is to be congratulated on independently rediscovering some key
concepts that are well known in the wider behaviour change literature.

Behaviour change interventions are more successful if they are targeted to
match the individual's behaviour change stage, decision making style and
major motivations etc. This is one of the main reasons why one-to-one sales
people are the most effective behaviour change agents. They can adapt their
messages immediately to match what will work with each individual.

However there is a time and place for untargeted interventions. eg if you
what to promote something new then everyone will be in the unaware stage.
Consequently, printed advertisements and using PR techniques to generate
reports in the general media can be more cost effective for gaining
awareness than sales people. Having gained awareness it then much easier
for the sales people to get individuals through the subsequent stages
towards lasting change.

For an introduction to such literature see a chapter from Libby Roughead's
masters thesis re drug reps:
www.healthyskepticism.org/reps/chap3.htm

In response to David's more recent question: In general the potential
problems with FDCs include:

1) encouraging "one size fits all" thinking will drug combinations where
doses of the individual drugs are best adjusted independently.

2) uncertainty re which drug is responsible for adverse effects or benefits
which sometimes can be reduced by introducing one drug at a time.

I don't know if either of those are issues with anti-HIV combinations.

regards,

Peter

Dr Peter R Mansfield
GP
Research Fellow, Department of General Practice, University of Adelaide
NHMRC Public Health Postgraduate Scholarship 250465
Flinders University Convocation Medal 2003
Director, Healthy Skepticism Inc
Improving health by reducing harm from misleading drug promotion.
peter@healthyskepticism.org
www.healthyskepticism.org
Webmaster and Treasurer, Doctors for the Environment (Australia)
Promoting health through care of the environment.
www.dea.org.au
34 Methodist St, Willunga SA 5172 Australia
ph/fax +61 8 8557 1040

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