Non - Adherence in Veterinary Medicine
Medicines will not work if you do not take them.
Adherence to therapies is a primary determinant of treatment success.
Recent reports of WHO showed that only 50% of patients with chronic diseases actually follow their prescribed treatment. Research in veterinary medicine is very limited, yet it raises concern for the number of animals who are given the medication according to the treatment plan.
Moreover, the life expectancy of pets is increasing and so does the number of animals dealing with chronic conditions. It is therefore safe to predict that the problem of non-adherence might worsen the next years.
It is a situation that as vets we need to deal with on a regular basis: owners requesting a new appointment because of the recurrence of a condition due to poor treatment implementation. Sometimes they might blame the treatment or the doctor, which causes additional strain to the doctor-owner relationship, deteriorating the quality of the treatment the patient receives.
Medication non-adherence threatens the healing process, increases morbidity and mortality and causes a big medical wastage. The most promising approach to deal with this issue is the use of behaviour change techniques. Such tools can help to build a relationship between the owner and the veterinarian, based in trust and absence of criticism.
The Capability, opportunity and motivation model of behaviour (COM-B)
The most well known model that is being used in medicine in order to facilitate cooperation and adherence to medication is the COM-B framework.
This psychological model, made in 2011 by Michie et al., takes into consideration a wide range of factors that can affect behaviour correlated to medical uptake.
It proposes that people need the Cooperation, Opportunity and Motivation in order to perform a specific behaviour. Moreover, it provides insights for why the desirable behaviour is not engaged in.
Capability: is the psychological (understand, remember, plan treatment) and physical (dexterity) ability to perform the recommended behaviour
Opportunity: comprises all the physical and social factors, external to the person, that enable or prompt his/hers behaviour
- quality of communication
- level of healthcare
- characteristics of the prescribed medication (dosage complexity, taste/smell of the drug)
Motivation: includes all the brain processes that boost and guide our behaviour
- reflective brain processes: perception of condition, feeling about treatment
- automatic brain processes: incentives to action (establish routines is a positive factor)
The COM-B framework explains a persons behaviour, so afterwards we can plan a strategy that can best correct the problem in any of the areas.
For example an owners education and training on the correct way to apply the flea treatment on their pet is unlikely to encourage regular application, if the reason of non-adherence is forgetfulness. Instead we can inform the patient on different online applications that can remind him/her to apply the prescribed product on a monthly basis.
This new approach provides us with a systematic way to recognise the reason of non-adherence behaviour and to plan effective ways to solve it.
Behaviour Change Techniques (BCTs)
Researchers identified 93 different BCTs. I am highlighting below those that are being used currently in medicine and how we can apply them, so as to promote veterinary medicines adherence.
Allow the owner to describe you what problems and challenges he/she is facing and how they manage to cope with the treatment plan.
After you can come up with practical strategies:
- changing timing
- changing medicines
- changing the timeline
- changing the form of the medication (e.g. from piles to syrup)
In case that an owner has a negative belief for a specific drug, such as antibiotics, or feels it is unnecessary, approach them in a nonjudgemental way. Instead of explaining the benefits and the necessity of the drug, ask them about their concerns.
Let them give you their explanations.
Reassure them that their opinion is valid and you are working together on it.
If they have any question/opinion regarding the condition and the treatment plan that is not valid, reassure them that it is a common view.
People need to feel that they are not on their own with their opinions.
They want to believe that more people will identify with them.
By winning their trust and acknowledging their need to be listened and to know that you are working together, in order to provide adequate care to their pet, it will be much easier to encourage the recommended behaviour.
- The behaviour change wheel: A new method for characterising and designing behaviour change interventions https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-6-42
- Applying COM-B to medication adherence http://www.ehps.net/ehp/index.php/contents/article/viewFile/ehp.v16.i1.p7/1072
- Adherence to long term therapies http://www.who.int/chp/knowledge/publications/adherence_report/en/
- The behaviour change wheel: A new method for characterising and designing behaviour change interventions https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096582/
- Medicines Adherence: Understanding and Changing Patients Behaviour MOOC https://www.futurelearn.com/courses/medicines-adherence-patient-behaviour/3/todo/27270