3.6 - Improving Adherence
Understanding adherence in psychology
Adherence refers to the extent to which individuals follow medical or health advice, such as taking prescribed medications or attending appointments. In children, low adherence can lead to poorer health outcomes, making it a key focus in health psychology.
Strategies for improving adherence in children
Several practical approaches can help children stick to their medication plans more reliably. These strategies aim to simplify the process and make it less daunting, while involving both children and parents.
Key strategies
- Simple regimes - Reducing the number of doses or steps makes it easier for children and parents to follow.
- Pleasant-tasting medicines - Flavouring medications to taste better encourages children to take them without resistance.
- Easy-to-take formats - Using liquids instead of tablets can make swallowing simpler, especially for younger children.
- Reminders for older children - Sending text messages acts as a prompt to remind them about doses or appointments.
- Regular contact with parents - Phone calls provide ongoing support and check-ins to ensure the plan is being followed.
- Involving children in plans - Discussing treatments with children, addressing their worries, and including them in decisions increases their commitment, as supported by research like Benn (2014).
Operant conditioning and asthma management
Operant conditioning is a learning process where behaviours are shaped through rewards (positive reinforcement) or punishments. This principle can be applied to health devices to encourage correct use, particularly in conditions like asthma, which involves breathing difficulties due to inflamed airways. Standard spacer devices, which are plastic containers that attach to inhalers to deliver medication more effectively, can feel intimidating for children as they fit over the mouth.
The Funhaler device
The Funhaler is an innovative spacer device designed for children with asthma. It incorporates operant conditioning by providing immediate rewards for proper use, such as activating spinners or a whistle when the child inhales correctly. This positive reinforcement makes the behaviour more likely to be repeated, turning medication time into a fun activity rather than a scary one. As a result, children are motivated to adhere to their asthma treatment regime.
Chaney et al. (2004) study on the Funhaler
This research examined how the Funhaler could improve adherence to asthma medication in young children compared to traditional spacer devices.
Method
- 32 children aged 1.5 to 6 years, all diagnosed with asthma and already using a standard spacer device.
- Recruited randomly from seven local clinics.
- Parents were initially telephoned before home visits.
- Informed consent was given, and parents completed an initial questionnaire about their child's current device, including issues with medication delivery and adherence.
- Children switched to the Funhaler for two weeks, with parental supervision.
- During this period, parents received a random phone check to confirm if medication was given the previous day.
- At the end, families were visited at home, and parents filled out a second questionnaire on the Funhaler experience.
Results
Adherence improved significantly with the Funhaler.
| Measure | Current device | Funhaler |
|---|---|---|
| Medicated the previous day | 59% | 81% |
| Using recommended 4+ breath cycles per delivery | 50% | 80% |
Children's attitudes and parental experiences also shifted positively.
| Aspect | Existing spacer device | Funhaler |
|---|---|---|
| Child's attitude: Pleasure | 10% | 61% |
| Child's attitude: Strong fear or dislike | 19% | 0% |
| Child's attitude: Panic or phobia | 31% | 0% |
| Parental approach: Completely happy | 10% | 61% |
| Parental approach: Dislike | 16% | 0% |
Conclusions
- The Funhaler shows promise for better managing asthma in young children by enhancing adherence.
- It could lead to improved clinical outcomes.
- Operant conditioning principles prove effective in encouraging medication use.
Evaluation
- Strengths include direct comparison of devices in a real-world setting, supporting behavioural theories.
- Limitations involve the small sample size, which reduces generalisability, and potential bias from parents wanting to appear diligent.
Individual behavioural techniques for adherence
Beyond devices, various techniques rooted in behavioural psychology can promote adherence across age groups. These methods tailor interventions to individual needs, using reinforcement or reminders to encourage positive health behaviours.
Key techniques
| Technique | Description | Strengths | Weaknesses |
|---|---|---|---|
| Contract | A verbal or written agreement between patient and practitioner outlining the regime, such as committing to exercise or diet changes. | Research like Neale (1991) shows contracts lead to more positive health changes than no contract. | May not work long-term (Bosch-Capblanch et al., 2007); studies are often small-scale with low validity. |
| Prompts | Reminders via texts, calls, or letters about medications or appointments. | A review by Schwebel and Larimer (2018) of 162 studies found them beneficial, cost-effective, and patient-friendly. | Not suitable for everyone, e.g., elderly people may not use texts effectively. |
| Customising treatment | Adapting the regime to fit the patient's lifestyle and abilities, using intervention mapping to identify needed changes and apply techniques like operant conditioning. | Evidence from Lakhanpaul et al. (2020) shows success in improving asthma understanding in specific communities, like South-East Asian families. | Can be expensive due to time for collaboration; risks insensitivity to cultural differences if not handled carefully. |
Yokley and Glenwick (1984) study on immunisation adherence
This study applied behavioural incentives to increase parents' adherence to immunising their children against preventable diseases.
Context and aim
In the 1980s, preventable diseases like polio and whooping cough killed over five million children worldwide. Yokley and Glenwick (1984) reported 10,000 cases of preventable diseases in the USA. The aim was to evaluate the impact of four incentive conditions on motivating parents to immunise pre-school children.
Method
- Field experiment with a longitudinal design, tracking changes over time.
- 715 pre-school children (50% female, 64% white) who needed at least one immunisation for diseases like diphtheria, tetanus, whooping cough, polio, measles, mumps, or rubella.
- Independent variables: Four prompt types (general, specific, specific with extended clinic access and perks, specific with monetary lottery).
- Dependent variables: Number of immunisations, clinic attendances, and total immunisations received.
- Controls: Two groups (contact and no-contact) received no prompts initially. A third control measure ensured parents with two or more immune-deficient pre-schoolers were assigned to conditions as families, to prevent siblings being in different conditions.
- Procedure: Participant record cards were created; participants randomly assigned to receive one of the four prompts; lottery drawn after two months for the money-incentive group; follow-up at three months.
Ethics
- No initial consent, raising concerns about manipulation.
- However, control groups later received prompts to ensure fairness.
Results
- Specific prompts with incentives showed the highest increases in immunisations compared to controls.
- For example, specific prompt plus monetary incentive led to around 32% increase after three months, while general prompts showed minimal impact (under 8%).
Conclusions
- Behavioural incentives effectively motivate immunisation adherence.
- A single general prompt is not enough to motivate parents to immunise children; targeted, rewarding approaches work better.
Evaluation
- Strengths: Random assignment boosts validity; standardised procedures enhance reliability.
- Weaknesses: Sample dropout (36.9% less than original) limits representativeness; findings may not generalise beyond the USA.
Methodological issues in adherence research
Studies on adherence often face challenges that affect their quality and applicability.
Strengths and weaknesses
| Strengths | Weaknesses |
|---|---|
| Experimental designs, like random assignment in Yokley and Glenwick (1984), minimise bias and increase validity. | Small or non-representative samples, e.g., Chaney et al.'s (2004) 32 Australian children, reduce generalisability. |
| Standardised procedures, as in Yokley and Glenwick, allow replication for reliability. | Social desirability bias, where parents over-report adherence to seem responsible, lowers validity. |
Issues and debates in adherence studies
Use of children in research
- Studies like Yokley and Glenwick (1984) focused on parental behaviour but involved children indirectly.
- Ethical safeguards included parental permission in Chaney et al. (2004) and post-study reminders for controls, ensuring no long-term disadvantage.
- Home-based settings minimise stress, aligning with guidelines for vulnerable participants.
Real-world applications
- Findings from Yokley and Glenwick suggest incentive programmes could boost immunisation rates in areas with low uptake, helping combat preventable diseases.
- Techniques like the Funhaler illustrate how behavioural psychology can create practical tools for everyday health management, potentially improving clinical outcomes globally.