Increase Adherence by 20% by Challenging Patients Beliefs

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About this podcast

John Weinman, PhD, Head of Health Psychology at Atlantis Healthcare and Professor of Psychology at King’s College, London, has been studying adherence for the past 25 years and one thing he has learned: Everything pharma thinks they know about adherence is wrong. Pharma’s traditional line of thinking is that patients simply don’t know enough about the treatment or just forget to take the medication. In reality, there could be anywhere between 20 to 30 reasons why a patient is nonadherent—and those reasons are very personal to that patient. Professor Weinman has discovered a way to identify the factors affecting each patient and what can be done to change the patient’s behavior in order to influence adherence. In fact, he offers a case study of a program that was able to improve adherence by 20%—and keep patients at that improved rate even after the program ended.

Podcast Transcript

Bud Bilanich: Hi, everybody. It’s Bud Bilanich and we have another issue of “Experts on Call” here. And boy, do we have an expert for you today. Dr. John Weinman is a professor in London and he’s agreed to share some of his thoughts with us on adherence. And John, from what I understand—first of all, welcome. But from what I understand, you’ve been doing a lot of work in the whole area of adherence. Could you just kind of tell us a little bit about what you’re doing and what your interests are?

John Weinman: Sure. My sort of overall interest is in how patients deal with illness, particularly with long-term illness. I’m really interested in all areas of their coping: How they make sense of the illness, how they deal with it, and how they manage it on a day-to-day basis. And about 25 years ago, I linked up originally with a pharmacist who came to me with this rather serious question about the patients he worked with just often not really following treatment, and it being a source of frustration to him, wanting to provide the best treatment for his patients. So, he and I worked together very closely. He ended up doing a PhD with me. He’s now one of the real leaders in the field. He’s just moved on.

So, really, my interests stem from that time, seeing adherence not only to medication but to all thoughts of other advice that clinicians give—lifestyle advice and other advice and so on—as a real challenge for researchers like myself who are interested in the psychology of illness and treatment. So, really, I’ve spent 25 years trying to understand all the different factors that can influence whether people do or don’t adhere to treatment, and to really get an understanding of that. There are a whole range of factors as a basis for being able to work with patients, so knowing what drives their adherence or their non-adherence, I can then begin to work with those patients to perhaps help deal with some of the barriers or change some of the issues that are in their minds and so on.

Bud Bilanich: Well, yeah, you took—your column, your recent PM360 column takes all that 25 years of knowledge and sort of condenses it into one page. So, congratulations on being able to do that. But you talk about how adherence is, from your perspective, is all about individual motivators and the barriers that individual human beings experience. And I think that’s a very fascinating way to think of it, and I think it’s slightly different from how we have been thinking about adherence. And so, could you talk a little bit more about what you’ve written in that column and what you’re finding?

John Weinman: Yeah. Okay, I mean, I think the traditional way if you look way back and think about adherence is that it was very much about people either not knowing what to do or not remembering what to do. You know? I think that’s—and a lot of people still think that’s what the issue is. So, there’s been a lot of effort put into helping healthcare professionals describe the treatment more clearly, give people little reminders, whether it be text messages or whatever. So—as if that’s the entire problem.

And while that is part of the problem, it’s only a pretty small part of the problem. I think what we’ve shown in our research is that there are probably three major groups of factors that influence whether somebody does or doesn’t adhere, what we call capability factors. In other words, things to do with people’s knowledge, their understanding, their psychological capability, their ability to plan and organize their day. And also, their physical capability: Whether they can literally use the inhaler, let’s say, or open the bottle top, or make the injection, and so on. So, there are capability factors that are important, but probably not crucial.

The crucial factors from our point of view are what we call the motivational factors. And the motivational factors are very much about what makes people really want to and feel they need to take their medicines. So, it’s very much about their beliefs: Their beliefs about their condition, their beliefs about their illness, their beliefs around the treatment, including both positive and negative beliefs, beliefs that people have about their need to take the treatment. But also, worries or concerns they might have about taking the treatment. Worries about dependency and side effects and so on.

And also, in that motivational—sort of under that motivational heading are factors such as the patient’s mood. You know? If people very—

Bud Bilanich: Mood?

John Weinman: Yeah. More commonly, people who have major long-term health problems are more likely to suffer, say, depression, anxiety, and so on because those problems carry a burden with them of various sorts. And if people—particularly if people are depressed, people are less likely to be motivated. We know that depression is associated with lower adherence consistently. And it’s, again, around that sort of very demotivating aspect of depression: People feeling it’s all too much, they can’t control it, it doesn’t make any difference, and so on. So, all of those are motivational factors. Belief factors, mood—you wanted to ask me something?

Bud Bilanich: Yeah, it seems like it’s a very nasty kind of downward spiral. It’s that you end up with some kind of a chronic illness, which leads you to be depressed in general about your health and your well-being, which then—from what your research is showing—leads you to sometimes be less likely to adhere because of the depression. And that’s a really tough place to be and I think something I think we need to be addressing to be able to help people deal with their condition.

John Weinman: Yeah.

Bud Bilanich: So, that’s a big problem.

John Weinman: I completely agree. I mean, depression is an important factor in adherence. But the important thing to note is it’s not the only factor. Just as in the past we thought it was all about forgetting or understanding, depression is one of the motivational factors that can really influence whether people are adherent or not. Because there are a lot of people who have a major condition, a major health problem such as diabetes or asthma and are not depressed, but they’re still not taking medicine, and often because, let’s say, their beliefs about their treatment or their illness just make it less likely.

For example, if someone with asthma who really doesn’t believe they have asthma all the time because their symptoms come and go, so their belief about their condition is that it’s a cyclical or phasic condition, and yet their clinician says to them, “I would like you to take this preventer medication every day to keep the asthma at bay”—or someone with, let’s say, hypertension who has no symptoms at all ever, they’re asked to take daily medication in order to prevent a long-term much worse outcome—those people may not believe because they don’t have symptoms every day or at all, they may not believe they really need to take the medicine. Or similarly, if they then start taking medicines and they develop side effects or feel things which they—they may actually feel they’re worse off, so they develop negative beliefs or concerns.

So, those are really important factors. And we know that beliefs probably—well, from my point of view, I think that beliefs are probably the single biggest factor that gets in the way of medicine taking.

But I should before I go to finish this bit is say that I think—I said there were three groups of factors: The capability factors that we’ve spoken about, the motivational factors that we’ve spoken about, but also what we call opportunity factors. And these are things outside the individual that can get in the way or stop them getting in the habit of good medicine taking. So, it could be financial factors—so, in some healthcare systems, probably particularly your own, financial factors may be a reason why someone is just not able to access their medicine, because they don’t have the funds.

But also, other factors outside the individual would include things like the support of their healthcare provider. If they have a very supportive and good healthcare provider, whether it’s their doctor or nurse or whatever, that can really enhance good medicine taking or get in the way of good medicine taking. And their support at home too. People who have good social support, people around them, people who are, for example, caregivers or partners or whatever who really are interested in their health, they can really be encouraging and make sure that they follow…

So, we’ve really got a lot of factors. As I said, we’ve got these three major groups of factors, and under each are a number of other factors. There’s probably really 20, 30 major factors which can influence whether any individual takes their medicine or not. And when you asked me about it being a very personal thing, it’s personal because for each individual the particular factors that influence their medication taking could be any or all of those factors I described. Okay? So, let’s say if we have 10 people with asthma who are not taking their medicine, for some it may be very much capability factors. You know, problems in using their inhaler or problems in just planning. For others, it may be very much around their beliefs. They really feel, they believe—they don’t believe they don’t need to take it every day, or they may have worries about taking sort of steroidal-type treatment and so on. And whereas, others may just have very unsupportive healthcare professionals or people around them that make it—may change their motivation or may make it less likely that they take it. So, for any individual we need to know what the factors are. That’s why it’s a very personal issue.

And even more complicated is that for any individual those factors may change over time. So, it’s not—it’s a dynamic process; it’s not a one-off. So, we need to make sure we very carefully screen people to understand what is it for them that’s getting in the way of good medicine taking, and to make sure we don’t just assume that it’s always going to be like that. We get back to them, or we check to see if maybe their motivational factors now are increasing or decreasing or whether—or whatever it is. You know?

Bud Bilanich: Well, you’ve set yourself quite a task here.

John Weinman: Yeah.

Bud Bilanich: And you’ve mentioned asthma a few times, and I know that you recently did a study where you were looking at adherence with patients with asthma. What did you find there that could be of interest to pharma marketers and might go beyond the results of the asthma study to just adherence in general as we’re trying to produce drugs that are going to increase people’s lives?

John Weinman: Yeah. Well, I think it’s a really nice example, that study. It’s a study in which we took people who we knew were—they were sort of youngish adults, 18 to 45, and they were identified as people who were non-adherent. And we put them into a trial, a randomized control trial. So, they were randomized either to their usual care, and where we regularly measured their level of adherence every six weeks to see what their levels were like over time, over a period of six to nine months. And then, we had another group who received, who we screened carefully at the beginning to identify the key beliefs for them about their asthma and about their asthma treatment. And on the basis of previous research we knew which factors were associated with poor adherence, so we identified for each individual the key beliefs that were—we knew would be a problem for them in taking their treatment.

Then, what we did—because we wanted a pretty simple, scalable, pretty cheap solution—we had, we developed a large bank of text messages that would be—form a sort of challenge to each individual about their beliefs. So, we messaged people with message that would sort of, if you like, challenge people about their asthma or their treatment. So, very, fairly simple text messages that were sent to them in a very personalized way. So, if we identified an individual who came on the program and we saw when as we assessed them in the beginning they didn’t have a particularly strong need and a belief in the need for their treatment, or if maybe they had some concerns about taking their medication every day, or whatever, or didn’t think their asthma was something that was present all the time, whatever it is, we then had a whole bank of messages which we sent out to that individual over the first six weeks. Quite a lot of messages, quite a few every week, very much targeted to counteracting their beliefs. The following six weeks, the number of messages reduced down so there was just sort of one or two a day. And then, the final six weeks—it was an 18-week program—they just had a couple of messages a week.

But the messages were always targeted to their own particular beliefs they had about their illnesses and treatment, so they were relevant to them. And we had a large bank of a couple of hundred text messages that we drew from so we didn’t have to repeat messages all the time. So, people got different sorts of challenges, but they were always relevant to them.

Bud Bilanich: So, their adherence improved—

John Weinman: So, what happened—

Bud Bilanich:            —relative to the—

John Weinman: Yeah. We measured—we measured—yeah. What we did is we measured adherence every six weeks, so three times up to the end of the 18-week program. What we found is that the people who were not on the program, their adherence level which was around 45% remained almost totally static over that time. So, even though we’re measuring their adherence it’s not changing, because we’re not doing anything to them.

The other group, their adherence levels went up by around 20%, up into the—up to about 65% of that group then became adherent and stayed the same over the 18-weeks. Now, the important thing is at that point we stopped messaging. And with a reminder-based program you then see that once you stop sending people reminders they go back to baseline. With our people, at six months and at nine months afterwards their adherence levels remain exactly the same. And what we’ve seen is we’ve changed their beliefs. What we do by challenging their beliefs in a very simple way—this is a very one-channel approach, one type of approach, and it was meant to be sort of cheap and scalable—and what we demonstrated was that we could change people’s beliefs and, much more important, we could improve their adherence as a result, as part of that motivational component of adherence.

Bud Bilanich: That’s fascinating.

John Weinman: Yeah.

Bud Bilanich: You know—and so, the communication channel you were using were text messages?

John Weinman: Yeah. Only one channel. Go on.

Bud Bilanich: Have you looked into other channels that could possibly have similar kinds of results?

John Weinman: Yeah, yeah. I mean, it—the—I think the best programs, and it’s been shown that the best programs to improve adherence or change any health-related behavior typically are multichannel interventions. So, if you can target people through a number of different sources, getting the strengths of those so, you can use, for example, emails. You can use interactive web-based systems, again, where you—people can reach in and they reach out. Providing people, again, with challenges to—or help in setting goals and maintaining goals and monitoring what they’re doing. So, using mobile phones, using apps. Using, obviously, interactive computer systems with email and other web-based challenges, as well as much more conventional approaches, such as, for example, sending out magazines which provide stories about patients a bit like them so they can read about how people dealt with challenges.

And also, another very powerful component of these interventions could be actual calls from their nurse or healthcare professional, either at regular intervals or allowing the patient to call that person. So,  these multichannel approaches, I think, turn out to be probably the most powerful.

But the limiting factor, obviously, is that some patients don’t like some channels or maybe find it difficult to use some channels. And there’s a cost factor as well, because with our asthma program we went for cheap, we went for scalable, but—and it’s a relatively simple solution. These more elaborate multichannel approaches are obviously more expensive for the healthcare provider, but ultimately are the more powerful ones, particularly ones where you give patients some choice as to the sort of channels they would like, that suit them best in terms of their use of different technologies and their whole day-to-day sort of lifestyle.

Bud Bilanich: It’s absolutely fascinating to me because in my work with my management students, when we talk about organizational changes we talk a lot about multichannel. So, it’s not all that surprising. But I think it’s a new way to think about adherence. And you’re right: I think that it puts—it can put somewhat of a burden on the healthcare provider. And so, how can a pharma—how can pharma marketers help healthcare providers with, say, a multichannel approach?

John Weinman: Well, obviously, I think that big pharma companies have a really important role in providing additional services. Because we know the adherence problem is so big if we’re looking at 40%-50% of patients not adhering. Really, the service they offer, as many pharma companies now acknowledge, needs to be beyond the product, beyond the pill. So, it needs to be a pill plus—pill plus some sort of support service.

So, pharma companies, I think, can play a massive role in getting—there are a number of companies around now to develop programs and develop interventional strategies which are offered to patients at the same time, when they are, let’s say, offered a new treatment. So, when they go to their pharmacy and start with a new treatment, patients can be offered a service, access to a support service, which should be free to patients but could be very much provided by the pharma—big pharma or, indeed, the healthcare provider—as part of their service to really maximize good medicine taking.

Bud Bilanich: So, you’ve been working with the folks at Atlantis Healthcare who work with pharma companies to figure out how to do this kind of stuff, which like most things seems to be simple in concept but probably difficult to implement. [Laughter]

John Weinman: Yeah. Well, it’s actually not that difficult to implement. The big problem, really—you know, I think we’ve now got, say, for example, you take Atlantis as an example, they’ve got very, very good programs which have been designed and developed by their health psychology team, which use multichannel approaches, really use our understanding of all those factors I talked about earlier to—that are influencing adherence, as well as an understanding of the different behavior change techniques. You need to change those factors, whether they’re beliefs or whether they’re just day-to-day patterns of regular planning and medicine taking. I mean, there are a whole lot of—those factors, they all need to be changed in different ways; they need different behavior changing techniques.

So, that is—that’s the science, if you like. The health psychology science of all of that is getting pretty well established. So, that’s not the difficulty. The difficulty—and also, turning those insights into really good, compelling programs, support programs for patients—again, we’ve become very good at that. I think what the block now is for healthcare systems to embrace these really innovative approaches. To be willing to pay for them as well. And also, to make sure that it’s easy for patients to enroll or engage with these programs. You know? Because I think there’s quite a lot of programs out there and some people have found that the uptake of them has not been that good. It’s almost like another adherence problem.

So, getting patients to engage with the programs—I think once patients are on these programs they get huge benefits. We’ve seen the huge benefits. So, making them almost a routine part of healthcare now, I think, is the challenge. Because the programs themselves are great and they’re well-developed.

Bud Bilanich: All right. Well, John, any last words of wisdom for pharma marketers here? And would you go over—and I think some of the best last words might be to just review your three major buckets before we sign off here.

John Weinman: Well, I think the key things for me and, I think, the key insights for pharma are firstly that the old ways of trying to segment patients haven’t worked. That really, the whole patient segmentation process has very much got to be based around our understanding of the drivers of their behavior. Okay? And as I’ve said, we know a lot about those drivers. So, really good screening of patients to understand the issues for them. Secondly, finding the best and most effective behavior change techniques and channels for dealing with those issues that the patients have. And thirdly, I think somehow being able to seamlessly put those programs in the patient pathway, in the clinical pathway for patients, to make them an everyday part of that clinical pathway in a way that clinicians should not feel threatened by. This is something which should very much support the clinician as well as the patient. We’re not trying to take anything away from the clinician. This has been—these are things that—these are ways in which we could really help improve effective healthcare and create effective healthcare for patients.

Bud Bilanich: Well, yeah. John, thank you. I know that you’re running up a deadline here.

John Weinman: Yeah.

Bud Bilanich: We try to keep these interviews short so pharma marketers are busy. I really appreciate it. And folks, I’ve been speaking with Professor John Weinman on the topic of adherence. You need to read his article in PM360. And check out the—what the folks at Atlantis Healthcare have to offer because they’re on the cutting edge of how we are dealing with patients with adherence issues.

So, John, again, thank you so much. I appreciate your time and tremendous information in a fascinating study that you did with the asthma patients and just showing how a small intervention like text messages can really improve adherence.

So, thank you so much for your time.

John Weinman: Thank you, Bud. It’s been a pleasure talking to you.

  • John Weinman, PhD

    John Weinman, PhD is Head of Health Psychology at Atlantis Healthcare and Professor of Psychology at King’s College, London. Professor Weinman is recognized as one of the founders of modern health psychology and respected as a preeminent global thought leader in the field. His main research areas are cognition and health, communication and decision-making in healthcare, and self-management and self-regulation in chronic illness.

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