(2003; 211 pages)
The role of psychologists in improving adherence to therapies
By Pierre L.-J. Ritchie. Secretary General. International Union of Psychological Sciences (IUPsyS)
Psychologists work as applied health researchers and practitioners in primary, secondary and tertiary care settings and as members of multidisciplinary teams of health service providers, as well as in independent practice. In these varied roles, the involvement of psychologists increases the effectiveness of programmes aimed at identifying and treating prevalent behaviourally-based health problems. Nonadherence is arguably the most widely distributed and prevalent of these problems.
The success of any treatment depends on both its efficacy and the manner in which a patient uses it. Adherence occurs in the process of adaptation to illness or to the threat of illness. While the past 50 years have witnessed considerable progress in developing powerful treatments for a wide variety of chronic and acute illnesses, patients' use of these treatments has been far from optimal. The global challenge now facing health systems is to become more effective in creating the conditions that enable people to derive maximum benefit from available treatments. Establishing the optimal conditions for adherence early in the treatment process sets the stage for long-term maintenance. Psychological science and practice concerning adherence focus on the systemic, biological, social, cognitive, behavioural and emotional contributing factors. Psychologists bring an understanding of both adaptive and maladaptive psychological, social and behavioural processes that are critical for understanding, preventing and treating nonadherence.
In every situation in which treatment involves an aspect of a patient's behaviour, adherence is a potential problem. This is the case for health-seeking behaviours, the self-administration of medication or making lifestyle changes. Adherence is a behavioural issue, and psychology is a behavioural discipline. It is therefore not surprising that psychologists have been very active in efforts to improve adherence since at least the 1950s. Furthermore, adherence to both medical and behavioural treatments has been a major subject of research and practice in health psychology and behavioural medicine since their emergence as specialty areas. Since the 1980s, many psychologists have embraced a population-health perspective, and have supported public health goals by putting psychological know-how to work at all levels of the health care system. Their work supports the development of effective health policy, surveillance of behavioural risk factors in the population, and the design, implementation and evaluation of interventions.
Psychologists have unique and specialized training. They are behavioural specialists, often trained as scientist - practitioners, who bring an evidence-based perspective to the problem of nonadherence. Through research and practice, psychologists have developed compelling, effective approaches to help patients to cope with the demands imposed by chronic illness that frequently contribute to nonadherence. Psychologists also possess expertise in interpersonal communication, and have contributed to knowledge concerning the importance of good communication between health providers and patients for promoting adherence. This has led to innovations in training in interpersonal skills for health service providers targeting this determinant. Recognition of the importance of psychological and behavioural skills in the training curricula of health disciplines has drawn further on the skills of psychologists as educators.
As a health discipline, psychology blends basic and applied scientific enquiry with clinical service delivery to increase knowledge about adherence behaviour and its determinants, and to improve people's health and well-being, and the quality and efficiency of health services. Psychology was founded in response to the need to understand, predict and influence such basic phenomena as human motivation, cognition and behaviour. Over time several sub-disciplines have emerged including, clinical, health, rehabilitation, community, experimental, organizational and social psychology. Each of these has made substantial contributions to the knowledge base on adherence.
As scientists, psychologists produce knowledge that helps to identify the causes of the nonadherence, develop and test theories that help to explain the mechanisms of causality and to design and evaluate interventions to increase adherence. In this regard, psychologists have contributed to adherence research and patient care in areas such as HIV/AIDS, diabetes, hypertension, obesity, ischaemic heart disease, stroke, chronic pain, asthma and chronic obstructive pulmonary disease, kidney disease, headache, addictions, seizure disorders, a range of mental illnesses and dental hygiene, as well as behavioural risk factors for illness such as poor diet, insufficient physical activity, smoking and risky sexual behaviours among others.
As health service providers and members of the health care team, psychologists bring unique skills in psychological assessment and behavioural measurement to help identify those patients at risk of nonadherence, and to identify the determinants of nonadherence where it has already become a problem. They bring sophisticated treatment skills to ameliorate these risk factors and determinants. These skills are applied to individuals, families, groups or communities in the service of illness prevention, acute and chronic care or rehabilitation. With regard to nonadherence, these skills are commonly used to address the cognitive, motivational, emotional and behavioural barriers to the self-management of illness, or the modification of health risk behaviours. In clinical service settings, psychologists function in varied roles; as providers of direct service, consultants to health care teams with respect to diagnosis and treatment planning, and patient advocacy.
In addition to the basic science, clinical and population health research described above, psychological practice in the area of adherence comprises:
- assessment of risk for nonadherence including the relative contributions of patient attributes, illness- and treatment-related factors, social context of illness, and health provider and system factors;
- assessment and treatment of mental health co-morbidities that confer additional risk for nonadherence;
- specific cognitive, motivational and behavioural interventions to enhance the ability of patients to manage their own illness or to reduce risk of illness;
- relapse prevention intervention to assist with the long-term maintenance of treatment;
- continuing education interventions for other health service providers that teach skills in communication, motivation enhancement, and behaviour modification; and
- systems interventions aimed at improving the availability, accessibility and acceptability of treatments.
Psychological service providers have an integral role in primary health care teams that aim to deliver optimal, cost-effective care. They contribute by monitoring the psychological and behavioural risks to patients' health, identifying and treating psychological and behavioural problems that threaten the effectiveness of treatment and they optimize treatment planning by helping to integrate behavioural science.