health psychology

PART 1: FOUNDATIONS – HEALTH, ILLNESS, AND THE PATIENT EXPERIENCE

Section 1: Learning Goals (Page 2)

By the end of this lecture, students will understand:

• The concept of health.

• Common health psychology models affecting behaviours.

• The use of Patient-Reported Outcome Measures (PROMs).

• The importance of adherence.

• Factors causing non-adherence.

• Communication and adherence.

• Services to enhance adherence.

Section 2: The Biopsychosocial Model – Understanding the Whole Person (Pages 4-5)

2.1. The Biopsychosocial Model (Page 4):

• This model provides a holistic framework for understanding health and illness, moving beyond the purely biomedical model. It considers three interconnected domains:

• Clinical Relevance: A patient's experience of illness and their response to treatment cannot be understood by biology alone. Their psychological state and social context are equally critical determinants of health outcomes and adherence.

2.2. Patient Narratives – The Hidden Burden of Illness (Pages 5-8):
These powerful quotes illustrate the profound psychological and social impact of illness, highlighting factors that influence adherence and engagement with healthcare.

• Quote 1 (Stigma and Pity): "I didn't tell anyone about my condition because I didn't want to have that look of pity in their eyes that truly hurts, that they feel sorry for me." (Page 5)

  • Psychological Impact: Fear of pity and being seen as a victim leads to social withdrawal and secrecy. This can isolate the patient, reducing access to social support which is crucial for coping and adherence.

• Quote 2 (Genetic Condition and Social Status): "In general, people are more aware that breast cancer can spread in families... In the end, this could affect someone's chances of getting married or her social status... because if they know that you have a gene, they might think that you're a 'flawed person'." (Page 5)

  • Social & Cultural Impact: A hereditary condition (like BRCA mutation) can be perceived as a personal flaw, impacting marriage prospects and social standing. This creates a powerful incentive for secrecy and non-disclosure, potentially affecting family communication and uptake of preventive or monitoring services.

• Quote 3 (Secrecy Within the Family): "When I received my diagnosis... I'm keeping it to myself, only few people know, and as a family, we're keeping it to ourselves." (Page 6)

  • Psychological & Social Impact: The patient chooses to conceal their diagnosis even from extended family, fearing social repercussions. This places an emotional burden on the immediate family and prevents them from accessing support.

• Quote 4 (Protecting Children and Treatment Preferences): "When I got the disease, my little child was 2 years old... I told my doctor I didn't want to get chemo again, so he prescribed a mouth pill, we decided not to tell anyone that it had returned, and my children have no idea what it means." (Page 6)

  • Psychological Impact: The desire to protect children from the emotional burden of a parent's illness is a powerful motivator. This patient also exercised autonomy in choosing an oral therapy over IV chemotherapy, demonstrating the importance of shared decision-making and respecting patient preferences to maintain adherence.

• Quote 5 (Fertility, Relationships, and Body Image): "I was divorced after 11 years of marriage and without children; someone wants to propose to me, and I want to be a mother... However, there is a slim probability that it will be successful. I'm not sure if he'd still come back and propose. You are also aware of the changes that occur following surgery. It's difficult to put into words." (Page 7)

  • Psychological & Social Impact: This quote reveals the complex interplay of fertility concerns, relationship uncertainty, and body image issues following cancer treatment. These factors can profoundly affect a patient's identity, self-worth, and future planning, which in turn can impact their mental health and engagement with long-term follow-up care.

2.3. Mental Health, Culture, and Stigma (Page 8):

• Survey Findings (N=130):

  • 61% felt their culture was not open and understanding towards mental health (most reflective of Black culture as they represented 68% of respondents).

  • ~50% were not open to being in a relationship with someone who had mental illness.

  • 42% would advise individuals with mental illness to seek religious help (rather than or in addition to medical help).

• Key Takeaway: Cultural beliefs and stigma surrounding mental illness are powerful barriers to seeking and adhering to treatment. Healthcare professionals must be culturally competent and sensitive to these factors.

Section 3: Cognitive Representations of Illness – Leventhal's Self-Regulatory Model (Pages 9-10)

3.1. The Five Core Illness Cognitions (Page 9):
Leventhal's model proposes that when faced with a health threat, individuals form parallel cognitive and emotional representations of their illness, which guide their coping behaviour. The cognitive representation has five key components:

1. Identity: The label or diagnosis given to the illness (e.g., "I have hypertension") and the symptoms associated with it (e.g., "I get headaches when my blood pressure is high"). This links the abstract label to concrete experience.

2. Cause: The patient's beliefs about what caused their illness. This can be biological (e.g., "It runs in my family"), environmental (e.g., "It was that infection"), behavioural (e.g., "I ate too much junk food"), or psychological (e.g., "It's all the stress at work").

3. Timeline: The patient's perception of how long the illness will last – acute (short-term), chronic (long-term), or cyclical (comes and goes). This affects their expectation for treatment duration and recovery.

4. Consequences: The patient's beliefs about the physical, social, and emotional impact of the illness. This includes limitations on daily life, impact on work/relationships, and financial implications.

5. Curability/Controllability: The patient's belief about whether the illness can be cured or managed, and who is responsible for this control (themselves, the doctor, the treatment).

3.2. The Self-Regulatory Model in Action (Page 10):

• Process: The illness representation (e.g., "I have diabetes – it's a chronic, serious condition caused by my lifestyle, but I can control it with medication and diet") leads to the selection of coping procedures (e.g., taking medication, changing diet, exercising).

• Outcome: The patient then appraises the effectiveness of their coping (e.g., "My blood sugar levels are better; I feel more energetic"). This appraisal can then modify their initial illness representation.

• Clinical Relevance: Understanding a patient's illness cognitions is crucial. If they believe their hypertension is an acute condition caused by stress (timeline incorrect) and will go away on its own, they are unlikely to adhere to lifelong medication. The HCP must address these beliefs.

PART 2: DEFINING ADHERENCE AND MODELS OF COMMUNICATION

Section 4: Key Definitions – Compliance, Adherence, Concordance (Pages 11-12)

4.1. The Terminology Evolution (Page 11):

• Compliance: "The extent to which the patient's behaviour matches the prescriber's recommendations." This is a paternalistic term, implying the patient is a passive follower of doctor's orders. Non-compliance is seen as the patient's fault.

• Adherence: "The extent to which the patient's behaviour matches agreed recommendations from the prescriber." This is a more collaborative term, implying a shared agreement and acknowledging the patient's active role in decision-making.

• Concordance: Predominantly used in the UK. It refers to the consultation process itself, where doctor and patient agree on therapeutic decisions that incorporate their respective views. It's about a successful negotiation, not just the outcome. It extends from prescribing communication to ongoing patient support in medicine-taking.

4.2. Clarifying the Relationship (Page 12):

• There is often a misconception that these terms are interchangeable.

• Adherence should be viewed as the primary aim (the goal of therapy).

• Concordance is the process used to apply the aim (the shared decision-making consultation).

• Compliance is the outcome of the process (the observable behaviour), but adherence is the preferred term for the desired outcome of a concordant process.

Section 5: Models of Communication and Adherence (Pages 13-17)

5.1. Ley's Cognitive Hypothesis Model (CHM) (1988) – Page 13:

• This model focuses on the cognitive factors within a consultation that influence a patient's satisfaction and subsequent adherence.

• Key Components:

  1. Understanding: Patients must understand the information given to them. If information is too complex or jargon-filled, understanding is compromised.

  2. Memory: Patients forget a significant portion of what they are told, especially if they are anxious. Recall is poorer for information given later in the consultation.

  3. Satisfaction: Patients who are satisfied with the consultation (e.g., felt listened to, got their questions answered) are more likely to adhere.

• The Chain: Understanding → Satisfaction → Adherence. If communication fails at any point, adherence suffers.

5.2. The Dichotomy in Consultations (Pages 14-15):

• The Patient's Perspective (Page 14):

  • Wants to be cured.

  • Wants to understand the means of getting cured.

  • Is anxious, which impairs recall.

  • Forgets to ask questions or report all symptoms.

  • Is concerned about symptoms, while the doctor is concerned with the disease.

• The HCP's Perspective (Page 15): Concerned with medical diagnosis and treating the illness biomedically. They define medical information objectively.

• The Problem: This creates a dichotomy. HCPs focus on objective disease, while patients experience illness subjectively in terms of personal relevance. This is the difference between disease-centred care (biomedical) and person-centred care (biopsychosocial).

5.3. Key Research Questions for Adherence (Page 16):

1. What are the most effective methods for addressing the cognitive (beliefs, attitudes), emotional, and capacity (memory limitations, routine changes) factors that result in reduced adherence?

2. How can we enable prescribers and the NHS workforce to support patients in facilitating informed choice and optimal adherence?

3. How can we incorporate awareness of patient needs into everyday healthcare delivery for greater efficiency?

5.4. Archetypal HCP-Patient Relationships (Roter & Hall, 1992) – Page 17:
This model describes the power dynamic in the consultation:

• Paternalism: The HCP is controlling; the patient is passive. The HCP decides what is best. (High HCP control, low patient control).

• Consumerism: The patient is the "consumer" who knows their needs and rights; the HCP has an obligation to provide the requested service. (Low HCP control, high patient control).

• Mutuality (Shared Decision Making): Power is shared. The HCP creates a conducive atmosphere, ascertains the patient's goals, educates, and seeks the patient's viewpoint. This aligns with the concept of concordance. (High HCP and high patient control, working together).

• Default: Neither party exerts control; no agreements are made. (Low control from both).

PART 3: PSYCHOLOGICAL MODELS OF ADHERENCE

Section 6: Rational Choice Theory (Page 18)

• Principle: People make decisions by weighing the benefits against the costs. They aim to maximise advantage and minimise harm or inconvenience.

• Application to Adherence: Patients assess:

  • Expected benefit of treatment (Will it make me better?).

  • Risks and side effects (Will it make me feel worse?).

  • Cost, effort, and inconvenience (Is it expensive? Is it hard to take?).

• Outcome: Treatment is more likely to be accepted and adhered to if the perceived benefits outweigh the perceived risks and costs.

• Example: A patient may decline a statin if they believe the risk of muscle pain (perceived side effect) outweighs the benefit of preventing a future, asymptomatic heart attack.

Section 7: Social Cognitive Models (Page 19)

• Principle: These models explain behaviour by considering:

  • Beliefs (about the illness and treatment).

  • Perceptions (of risk and control).

  • Social influences (norms, support).

  • Confidence in ability to act (self-efficacy).

• Common Models:

  • Health Belief Model (HBM)

  • Protection Motivation Theory (PMT)

  • Theory of Reasoned Action (TRA)

  • Theory of Planned Behaviour (TPB)

• Value: These models help explain why people do or do not follow treatment advice, even when they have all the necessary information.

Section 8: Health Belief Model (HBM) (Page 20)

• Key Components: The likelihood of a person engaging in a health behaviour (like taking medication) is determined by their beliefs in five core areas:

  1. Perceived Susceptibility: "How likely am I to get worse if I don't take this?" (e.g., "My blood pressure is high, but I feel fine, so I'm not really at risk.")

  2. Perceived Severity: "How serious would the consequences be?" (e.g., "A heart attack would be devastating and could kill me.")

  3. Perceived Benefits: "Will taking this treatment actually help me?" (e.g., "This statin will lower my cholesterol and reduce my risk.")

  4. Perceived Barriers: "What are the downsides?" (e.g., "It gives me muscle aches, it's expensive, I have to remember to take it every day.")

  5. Cues to Action: Triggers that prompt action. (e.g., experiencing symptoms, a reminder from a pharmacist, a health scare in the family).

• Evidence: Adams & Scott (2000) found that severity of illness and perceived treatment benefits explained 43% of the variance in adherence.

• Clinical Relevance: Patients are more adherent when they believe the illness is serious AND the treatment is effective. The HBM helps identify which belief is lacking and needs to be addressed.

Section 9: Protection Motivation Theory (PMT) (Pages 21-22)

• Principle: Behaviour is driven by a combination of fear (threat appraisal) and the belief that one can successfully cope (coping appraisal).

9.1. Threat Appraisal (Page 22):

• What it involves:

  • How serious the patient believes the condition is.

  • How vulnerable they feel to negative outcomes.

• Impact on behaviour:

  • Higher perceived threat can motivate action.

  • However, excessive fear may lead to avoidance, denial, or disengagement (e.g., "It's too scary, I don't want to think about it, so I won't take the test/treatment").

• Clinical Balance: HCPs must communicate risk clearly but avoid causing unnecessary alarm, supporting informed, calm decision-making.

9.2. Coping Appraisal (Page 21):

• Involves two key beliefs:

  • Response Efficacy: Belief that the recommended behaviour will work (e.g., "This medication will effectively control my HIV").

  • Self-Efficacy: Belief in one's own ability to perform the behaviour (e.g., "I am confident I can adhere to this daily medication regimen").

• Outcome: Patients are more likely to act when they:

  1. Believe the health threat is real and serious.

  2. Believe the treatment will be effective.

  3. Feel capable of following the treatment.

9.3. Self-Efficacy (Conn, 1998) – Page 23:

• Definition: A person's belief in their ability to successfully perform a specific behaviour.

• Why it matters: High self-efficacy is a strong predictor of higher adherence. Low self-efficacy leads to avoidance or disengagement.

• In Practice: HCPs can boost self-efficacy by:

  • Simplifying regimens.

  • Providing education and reassurance.

  • Teaching and practicing skills (e.g., correct inhaler technique, blood glucose monitoring).

Section 10: Theory of Reasoned Action (TRA) and Theory of Planned Behaviour (TPB) (Pages 24-26)

10.1. Theory of Reasoned Action (TRA) (Page 24):

• Principle: Behaviour is directly driven by intention.

• Intention is influenced by:

  1. Attitudes toward the behaviour: The person's positive or negative evaluation of performing the behaviour (e.g., "Taking this medication every day is a good thing to do").

  2. Subjective norms: The person's perception of what important others (family, friends, HCPs) think they should do (e.g., "My wife thinks I should take my heart medication").

• Limitation: TRA assumes behaviour is fully under voluntary control. It doesn't account for factors that might prevent a person from acting on their intention (e.g., lack of skill, resources).

10.2. Subjective Norms and Social Norms (Page 25):

• Subjective Norms: Beliefs about what specific, important others think. (e.g., family, clinicians). Adherence improves when treatment is socially supported.

• Social Norms: What is seen as "normal" behaviour in a wider group or society. (e.g., "In my community, it's normal to take herbal remedies for diabetes, not pills"). Patients are more likely to adhere if they feel their behaviour is normal and accepted.

10.3. Theory of Planned Behaviour (TPB) (Page 26):

• Extension of TRA: Adds a third predictor of intention:

  • Perceived Behavioural Control: The person's perception of how easy or difficult it will be to perform the behaviour. This is similar to self-efficacy.

• Three Predictors of Intention:

  1. Attitude toward the behaviour.

  2. Subjective norms.

  3. Perceived behavioural control.

• Clinical Relevance: Even motivated patients may not adhere if they feel the treatment is too complex or they lack the ability to manage it. This model highlights the need to address both intention and practical barriers.

PART 4: THE SPUR MODEL – A MULTIDIMENSIONAL FRAMEWORK

Section 11: The SPUR Model of Medication Adherence (Pages 27-31)

11.1. What SPUR Stands For (Page 27):
The SPUR model was developed to understand and predict medication adherence by integrating multiple behaviour theories into one practical framework.

• S – Social:

  • Influence of: Family, peers, culture, healthcare professionals.

  • Factors: Social support, stigma, social and cultural expectations, relationships with HCPs.

• P – Psychological:

  • Influence of: Beliefs, emotions, motivation, attitudes toward illness and treatment.

  • Factors: Fear of side effects, confidence in treatment, health beliefs (HBM, PMT), mental health, coping styles.

• U – Usage:

  • Influence of: The practical ability to take the medicine correctly.

  • Factors: Complexity of regimen, forgetfulness, understanding instructions, physical ability (dexterity, swallowing), access to medicines.

• R – Rational:

  • Influence of: The patient's evaluation of risks and benefits.

  • Factors: Perceived effectiveness vs. perceived side effects, cost-benefit analysis (Rational Choice Theory), necessity beliefs vs. concerns (BMQ).

11.2. Why the SPUR Model is Useful (Pages 28-30):

• Integrative: It combines multiple behaviour theories into one cohesive framework.

• Multifactorial: It recognises that non-adherence is rarely due to a single cause but is often a combination of social, psychological, practical, and rational factors.

• Diagnostic: It helps identify why a patient may not be adhering, not just whether they are. This allows for targeted, personalised interventions.

• Example: A patient may understand the benefits (R) but struggle with routine (U) or lack social support (S). The SPUR model helps pinpoint the specific barrier.

11.3. Application in Healthcare (Page 29):
The SPUR model can be used to:

• Identify adherence barriers.

• Tailor interventions to individual patients.

• Support shared decision-making.

• Improve long-term treatment outcomes.

11.4. Key Research (Page 30):
The slide lists several research papers validating the SPUR model, demonstrating its application and predictive validity in conditions like Type 2 Diabetes and COPD. It has been developed into a patient-reported outcome measure (PROM) tool (SPUR-27, SPUR 6/24) to quantify these dimensions.

• Wells J, Wang C, Dolgin K, Kayyali R. SPUR: A Patient-Reported Medication Adherence Model as a Predictor of Admission and Early Readmission in Patients Living with Type 2 Diabetes. Patient Prefer Adherence. 2023.

• Wells J, Mahendran S, Dolgin K, Kayyali R. SPUR-27 - Psychometric Properties of a Patient-Reported Outcome Measure of Medication Adherence in Chronic Obstructive Pulmonary Disease. Patient Prefer Adherence. 2023.

• Dolgin, K., Kayyali, R., Wells, J. et al. Predicting and understanding non-adherence in chronic disease: cross-cohort validation and structural equation modeling of the SPUR 6/24 tool. Sci Rep 15, 33216 (2025).

11.5. Key Messages from SPUR (Page 31):

• Treatment decisions are influenced not only by clinical evidence, but also by beliefs, confidence, perceived risk, and social context.

• Effective care requires understanding how patients think, not just what they are prescribed.

• Improving adherence requires addressing social, psychological, practical, and rational factors together.

PART 5: PATIENT-REPORTED OUTCOME MEASURES (PROMs) IN ADHERENCE

Section 12: What are PROMs and Why Do They Matter? (Pages 32-34)

12.1. Definition (Page 32):

• Patient-Reported Outcome Measures (PROMs) are tools (usually questionnaires) that capture patients' own views about their health, treatment, and behaviours, without clinician interpretation.

• In adherence, PROMs help identify:

  • Why patients may not take medicines as prescribed.

  • Beliefs, barriers, and practical difficulties.

  • Areas for targeted intervention.

12.2. Common Adherence PROMs (Page 33):

12.3. Why PROMs Matter (Page 34):

• They move the conversation beyond "did the patient take it?" to "why or why not?"

• They reveal modifiable belief-based and practical barriers.

• They enable patient-centred, shared decision-making.

• They align closely with HBM principles by quantifying patient perceptions.

• Conclusion: Medication adherence is shaped by social, psychological, practical, and rational factors, and PROMs such as SPUR provide a structured way to identify and address these influences.

PART 6: FACTORS CAUSING NON-ADHERENCE AND STRATEGIES FOR IMPROVEMENT

Section 13: The Scale of the Problem and Consequences (Pages 36-37)

• Scale (Page 36): Non-adherence is a widespread and significant problem across all areas of medicine.

• Consequences of Non-adherence (Page 37):

  • For the Patient: Poor health outcomes, disease progression, increased morbidity and mortality, reduced quality of life.

  • For the Healthcare System: Increased hospital admissions, emergency department visits, higher treatment costs, wasted medicines.

Section 14: Factors Affecting Adherence – Causes of Non-Adherence (Pages 38-40)

Adherence is a complex behaviour influenced by a wide range of factors, which can be broadly categorised as unintentional or intentional.

14.1. Unintentional Non-Adherence (Page 38):
These are factors that prevent a patient from taking their medication as prescribed, even if they intend to.

• Forgetfulness: Dose omission, taking extra doses, taking at the wrong time, not taking at all.

• Difficulty in Taking: Size/shape of tablets, type of inhaler, child-resistant containers (CRCs), blister packs.

• Difficulty Reading Instructions/Label: Poor vision, small font, complex language.

• Effect of Co-morbidities/Disability: Physical or mental disability affecting medicine-taking behaviour.

14.2. Intentional Non-Adherence (Pages 39-40):
These are factors where the patient makes a conscious decision not to take their medication as prescribed.

• Beliefs and Perceptions about Treatment (Page 39):

  • Purpose of treatment unclear.

  • Perceived lack of effect.

  • Real or perceived side effects/dependence.

  • Complex regimens (multiple drugs/doses).

  • Risks perceived as outweighing benefits.

  • Symptomless disease – "Why bother?"

  • Unhappy with formulation (taste, shape, colour).

• Psychological and Social Factors (Page 40):

  • Fear of drug taking.

  • Not wanting the label or stigma of illness.

  • Inconvenience of timing of doses.

  • Lack of confidence in prescriber.

  • Poor counselling/education.

  • Foreign medicine / Brand-generic switching.

  • Cost.

  • Influence of information sources (media, internet, family/friends' experiences) – particularly important in vaccine hesitancy (e.g., COVID-19 vaccine).

Section 15: Strategies for Improving Adherence (Pages 41-46)

15.1. Better Knowledge and Education (Page 41):
Patients need to be educated on:

• The Disease: What is the drug for? (Condition description).

• The Drug: How does it work?

• Treatment Benefits: Why is it being taken?

• Side Effects: What to do if experienced.

• How to Use Medicines: How much to take, what to expect.

• What to Do if Doses Missed.

• Duration of Treatment.

• Others: Lifestyle/dietary changes, storage, etc.

15.2. Simplify Drug Regimens (Page 42):

• Reduce polypharmacy where possible.

• Use combination products.

• Aim for once or twice daily dosing.

• Use sustained-release (SR) or modified-release (MR) preparations.

• Shorten duration of treatment when clinically appropriate.

• Provide clear guidance on use of devices (e.g., inhalers – link to Asthma UK resources).

15.3. Address Problems Linked with Physical Disabilities (Pages 43-44):

• CRCs (Child-Resistant Containers): Consider not using if patient struggles.

• Inhalers: Offer different types, spacers, devices like Haleraid to assist with use.

• Blister Packs: Recommend devices like Pill Popper to help open.

• Eye Drops: Recommend devices like Opticare or eye drop dispensers to assist with insertion.

• Magnifying Glass: To aid reading labels.

• Change Formulations: e.g., small tablets vs large; solid vs liquid if swallowing difficulties.

15.4. Address Forgetfulness (Page 45):

• Compliance Aids:

  • Calendar packs.

  • Compliance boxes / Monitored Dosage Systems (MDS) – dosette boxes, blister packs.

• Tailoring: Match doses to specific daily tasks (e.g., "take with breakfast").

• Involving/Talking to Carers.

• Reminders:

  • SMS, texts, telephone calls.

  • Medication Administration Record (MAR) charts.

  • Stickers.

  • Different colour labels (be mindful of colour blindness).

15.5. Medicines Reconciliation – A Key Safety and Adherence Tool (Pages 46-49):

15.5.1. Definition (Page 46):

• Medicines reconciliation is defined by the Institute for Healthcare Improvement (IHI) as: "the process of obtaining an up-to-date and accurate medication list that has been compared to the most recently available information and has documented any: discrepancies, changes, deletions and additions resulting in: a complete list of medications, accurately communicated."

15.5.2. The 3Cs Approach (Page 46):

• Collect: Gather the best possible medication history (BPMH).

• Confirm: Verify the accuracy of the history.

• Complete: Ensure the final list is accurate and communicated.

15.5.3. Steps in Medicines Reconciliation (WHO) (Page 47):

1. Obtain a best possible medication history (BPMH).

2. Confirm the accuracy of the history.

3. Reconcile BPMH with prescribed medicines.

4. Supply accurate medicines information (accurate record).

15.5.4. Case Study: Admission Medication Reconciliation (Pages 48-49):

• Patient History (Home Meds):

  • Metformin 1g BD

  • Gliclazide M/R 120mg OM

  • Sitagliptin 100mg OM

  • Ramipril 7.5mg OM

  • Apixaban 5mg BD

• Drug Chart (Hospital Admission):

  • Metformin 500mg OD

  • Gliclazide M/R 60mg OM

  • Sitagliptin 100mg OM

  • Ramipril 2.5mg OM

  • Apixaban 5mg BD

• Discrepancies Spotted:

  • Metformin: Home dose 1g BD (2000mg/day) vs hospital chart 500mg OD (500mg/day) – significant underdose.

  • Gliclazide: Home dose 120mg OM vs hospital chart 60mg OM – underdose.

  • Ramipril: Home dose 7.5mg OM vs hospital chart 2.5mg OM – underdose.

  • Apixaban: Correctly transcribed.

  • Sitagliptin: Correctly transcribed.

• Clinical Relevance: These discrepancies could lead to hyperglycaemia (underdosing of diabetes meds) and hypertension (underdosing of ramipril) during admission. Reconciliation catches these potentially harmful errors. It also ensures the patient's own routine is understood, which aids in planning discharge and maintaining adherence.

15.5.5. Patient Journey (Page 49): A diagram illustrating the patient's movement through care settings (admission, transfer, discharge) and the critical points where medication reconciliation should occur.

15.6. New Medicine Service (NMS) (Page 50):

• Question: What are the key steps and knowledge points that should be covered when conducting an NMS patient engagement consultation with a patient who has been started on ramipril 2.5 mg for hypertension, as a means of improving medicine adherence?

• Key Steps:

  1. Engage: Establish rapport, explain purpose of NMS.

  2. Assess Understanding: Ask patient what they know about ramipril, why they are taking it, and any concerns.

  3. Provide Information (as per Section 15.1): Explain what hypertension is, how ramipril works (lowers BP by relaxing blood vessels), the benefits (reduces risk of stroke/heart attack), common side effects (cough, dizziness) and what to do.

  4. Address Practicalities: Discuss when to take it (e.g., morning), what to do if a dose is missed.

  5. Explore Perceptions: Ask about any concerns (BMQ – necessity vs concerns). Use HBM: "How serious do you think high BP is?" "How effective do you think this medicine will be?"

  6. Check Self-Efficacy: "How confident do you feel about taking this every day?"

  7. Agree a Plan: Follow-up call (NMS involves 2 follow-ups) to see how they are getting on, check for side effects, and reinforce adherence.

  8. Document and Communicate: Record the consultation and any actions.

15.7. Discharge Medicines Service (DMS) (Page 51):

• The DMS is an NHS service to improve the transfer of care from hospital to community. It involves the hospital notifying the patient's community pharmacy of a discharge, enabling the pharmacist to provide follow-up support, including medicines reconciliation at home, to prevent post-discharge problems and improve adherence.

PART 7: SUMMARY AND KEY REFERENCES

Section 16: Summary

• Adherence is a complex, multidimensional behaviour influenced by social, psychological, practical, and rational factors.

• Psychological models (HBM, PMT, TPB, SPUR) provide frameworks for understanding why patients do or do not adhere.

• Communication is central to adherence. Moving from paternalism to mutuality (shared decision-making) is key.

• PROMs like SPUR are valuable tools for identifying individual barriers to adherence and tailoring interventions.

• HCPs can improve adherence through better education, simplifying regimens, addressing practical and physical barriers, using reminders, and providing structured services like Medicines Reconciliation, NMS, and DMS.

• Ultimately, effective care requires understanding how patients think and feel, not just what they are prescribed.