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New research links adherence in IBD to individual beliefs and concerns

Posted Jul 01 2009 6:45pm

New research investigating the impact that patients’ attitudes to maintenance therapy (MT) has on nonadherence in Inflammatory Bowel Disease (IBD) has been published today in Inflammatory Bowel Diseases.  Nonadherence is a common problem in most chronic conditions and the research found that low adherence to maintenance therapy (MT) in IBD was reported by 29% of participants.  Patients reporting low adherence were significantly more likely to harbour doubts about MT, stemming from their personal beliefs about the necessity of medication to control their condition, as well as having concerns that regular, long-term use of MT is associated with side effects and the risk of dependence.

In IBD, patients who do not take their medication regularly run a higher risk of increased morbidity, including a greater risk of relapse, reduced quality of life and a possible increased risk of colorectal cancer. Nonadherence is also likely to mean patients are more likely to need increased medical care.

Traditionally, it was thought that factors such as being single, gender and multiple dosing regimens were associated with lower levels of adherence. However, the research showed that socio-demographic factors and dosing frequency per se are not the key issues, but rather how well the treatment fits with the individual patient’s routine, expectations and preferences. Nonadherence can be both unintentional (e.g., when a patient intends to take the treatment but forgets) and intentional (e.g., when a patient decides not to take their medication).

“Our research was based on the concept that adherence is a variable behaviour, rather than a trait characteristic – we are all nonadherent some of the time!” said Professor Rob Horne, Professor of Behavioural Medicine and Director of the Centre for Behavioural Medicine. “To understand nonadherence we need to take a no-blame approach, and try to see the illness and treatment from the patient’s perspective. To do this, we studied patients’ personal beliefs about their prescribed medicines and how their beliefs related to adherence.”

The new research used the Necessity Concerns Framework (NCF) to gain insight into the beliefs that are held about MT prescribed for IBD, and to explore the association between such beliefs and adherence to treatment.

Results showed that while almost half (48%) of the participants were ‘accepting’ of MT, a large proportion of the sample (42%) were ‘ambivalent’ about MT , 6% were ‘sceptical’ and 4% were ‘indifferent’. Compared to those who were ‘accepting’ of MT, participants in all three other attitudinal groups (52%) were significantly more likely to be nonadherent.

“What we found is that the way in which patients judge their personal need for MT relative to their concerns about MT can be a significant barrier to adherence,” said Richard Driscoll, Chief Executive, NACC.   “In many ways this approach to investigating nonadherence seems like common sense – yet it has never been done before in IBD.  If we are going to succeed in increasing the number of patients who are taking their MT regularly, we need to give more emphasis to educating patients and make sure we are addressing their individual beliefs and concerns.”

Efforts to support adherence will therefore be more effective if they are tailored to the needs of individuals and take account of the perceptual factors (e.g., beliefs and preferences) influencing patients’ motivation to start and continue with treatment as well as the practical factors (e.g., capacity and resources) influencing their ability to adhere to the agreed treatment.

Fellow study author and practicing gastroenterologist Dr Andrew Robinson, Consultant Gastroenterologist, Salford Royal Foundation Trust, said, “This research maps out a totally different approach to thinking about and addressing nonadherence which could, in the future, play a significant role in improving IBD patient outcomes. To address nonadherence we need to encourage patients to discuss their use of medicines and any doubts or concerns they may have about the treatment.”

This research is very timely in light of the new NICE clinical guideline, Medicines adherence published in January this year. The guideline outlines how healthcare professionals can involve patients in decisions about prescribed medicines and support adherence.

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Tags: Inflammatory Bowel Disease, maintenance therapy, NACC

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