Rob Horne

Understanding Patients’ Adherence-Related Beliefs about Medicines Prescribed for Long-Term Conditions: A Meta-Analytic Review of the Necessity-Concerns Framework

Background Patients’ beliefs about treatment influence treatment engagement and adherence. The Necessity-Concerns Framework postulates that adherence is influenced by implicit judgements of personal need for the treatment (necessity beliefs) and concerns about the potential adverse consequences of taking it. Objective To assess the utility of the NCF in explaining nonadherence to prescribed medicines. Data sources We searched EMBASE, Medline, PsycInfo, CDSR/DARE/CCT and CINAHL from January 1999 to April 2013 and handsearched reference sections from relevant articles. Study eligibility criteria Studies using the Beliefs about Medicines Questionnaire (BMQ) to examine perceptions of personal necessity for medication and concerns about potential adverse effects, in relation to a measure of adherence to medication. Participants Patients with long-term conditions. Study appraisal and synthesis methods Systematic review and meta-analysis of methodological quality was assessed by two independent reviewers. We pooled odds ratios for adherence using random effects models. Results We identified 3777 studies, of which 94 (N = 25,072) fulfilled the inclusion criteria. Across studies, higher adherence was associated with stronger perceptions of necessity of treatment, OR = 1.742, 95% CI [1.569, 1.934], p<0.0001, and fewer Concerns about treatment, OR = 0.504, 95% CI: [0.450, 0.564], p<0.0001. These relationships remained significant when data were stratified by study size, the country in which the research was conducted and the type of adherence measure used. Limitations Few prospective longitudinal studies using objective adherence measures were identified. Conclusions The Necessity-Concerns Framework is a useful conceptual model for understanding patients’ perspectives on prescribed medicines. Taking account of patients’ necessity beliefs and concerns could enhance the quality of prescribing by helping clinicians to engage patients in treatment decisions and support optimal adherence to appropriate prescriptions.

Patients' interpretation of symptoms as a cause of delay in reaching hospital during acute myocardial infarction

OBJECTIVE To examine whether the association between expected symptoms of acute myocardial infarction and actual symptoms predicted delay in reaching hospital and help seeking behaviour. DESIGN During hospital convalescence, participants completed a structured interview designed to measure symptom experience and help seeking behaviour following the onset of symptoms of acute myocardial infarction. PATIENTS 88 patients admitted to hospital with their first myocardial infarction MAIN OUTCOME MEASURES Delay in reaching hospital from onset of worst symptoms, obtained from ambulance and hospital records. RESULTS The most common symptoms expected by patients with myocardial infarction were central chest pain (76%), radiating arm or shoulder pain (34%), and collapse (26%). The most common symptoms experienced were sweats or feeling feverish (78%), chest pain (64%), and arm, shoulder, or radiating pain (66%). A mismatch between symptoms experienced and those expected occurred in 58% of patients, and was associated with delay. Patients who experienced a mismatch between expectation and actual symptoms also were more likely to have a third party decide to call for help. CONCLUSIONS The experience and interpretation of symptoms is an important source of delay and help seeking following onset of myocardial infarction symptoms.

British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2015

Writing Group Duncan Churchill, Chair, Royal Sussex County Hospital, Brighton, UK Laura Waters, Vice Chair, Mortimer Market Centre, London, UK Nadia Ahmed, Mortimer Market Centre, London, UK Brian Angus, University of Oxford, UK Marta Boffito, Chelsea and Westminster Hospital, London, UK Mark Bower, Chelsea and Westminster Hospital, London, UK David Dunn, University College London, UK Simon Edwards, Central and North West London NHS Foundation Trust, UK Carol Emerson, Royal Victoria Hospital, Belfast, UK Sarah Fidler, Imperial College School of Medicine at St Mary’s, London, UK †Martin Fisher, Royal Sussex County Hospital, Brighton, UK Rob Horne, University College London, UK Saye Khoo, University of Liverpool, UK Clifford Leen, Western General Hospital, Edinburgh, UK Nicola Mackie, Imperial College Healthcare NHS Trust, London, UK Neal Marshall, Royal Free Hospital NHS Trust, London, UK Fernando Monteiro, UK-CAB Mark Nelson, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK

Patients' perceptions of highly active antiretroviral therapy in relation to treatment uptake and adherence : The utility of the necessity-concerns framework

Objective:To test the utility of the necessity-concerns framework in predicting highly active antiretroviral therapy (HAART) uptake and adherence. Methods:This was a prospective follow-up study. Consecutive patients who were not currently receiving HAART were referred by their HIV physician. Immediately after a recommendation of HAART, patients completed the Beliefs about Medicines Questionnaire assessing their perceptions of personal necessity for HAART and concerns about potential adverse effects. The influence of these beliefs on the decision to accept or decline HAART and adherence 12 months later were assessed. Results:One hundred fifty-three participants were given a recommendation of HAART, and 136 (88.9%) returned completed questionnaires. Thirty-eight participants (28%) initially rejected the treatment offer. Uptake of HAART was associated with perceptions of personal necessity for treatment (odds ratio [OR] = 7.41, 95% confidence interval [CI]: 2.84 to 19.37) and concerns about potential adverse effects (OR = 0.19, 95% CI: 0.07 to 0.48). There was a significant decline in adherence over time. Perceived necessity (OR = 2.19, 95% CI: 1.02 to 4.71) and concerns about adverse effects (OR = 0.45, 95% CI: 0.22 to 0.96), elicited before initiating HAART, predicted subsequent adherence. These associations were independent of clinical variables and depression. Conclusions:The necessity-concerns framework is a useful theoretic model for understanding patient perspectives of HAART and predicting uptake and adherence, with implications for the design of evidence-based interventions.

The value of self-report assessment of adherence, rhinitis and smoking in relation to asthma control

AIMS To explore the utility of self-report measures of inhaled corticosteroid (ICS) adherence, degree of rhinitis and smoking status and their association with asthma control. METHODS Patients prescribed ICS for asthma at 85 UK practices were sent validated questionnaire measures of control (Asthma Control Questionnaire; ACQ) and adherence (Medication Adherence Report Scale), a two-item measure of smoking status, and a single-item measure of rhinitis. RESULTS Complete anonymised questionnaires were available for 3916 participants. Poor asthma control (ACQ >1.5) was associated with reported rhinitis (OR = 4.62; 95% CI: 3.71-5.77), smoking (OR = 4.33; 95% CI: 3.58-5.23) and low adherence to ICS (OR = 1.35; 95% CI: 1.18-1.55). The degree of rhinitis was important, with those reporting severe rhinitis exhibiting the worst asthma control, followed by those reporting mild rhinitis and then those reporting no rhinitis symptoms (F(2, 3913)=128.7, p<.001). There was a relationship between the number of cigarettes smoked each day and asthma control (F(5,655)=6.08, p<.001). CONCLUSIONS Poor asthma control is associated with self-reported rhinitis, smoking and low medication adherence. These potentially modifiable predictors of poor asthma control can be identified through a brief self-report questionnaire, used routinely as part of an asthma review.

Worries about modernity predict symptom complaints after environmental pesticide spraying.

Objective: Concerns about environmental and technological changes affecting health have been shown to be associated with symptom reports in cross-sectional studies. We aimed to investigate how worries about modernity affecting health, negative affectivity, and prior symptom complaints influence health complaints after environmental spraying in a prospective study. Methods: Two hundred ninety-two residents of West Auckland completed questionnaires measuring recent symptoms, negative affect, and concerns about the effects of modernity on health before aerial spraying of their neighborhood with Foray 48B. After spraying, 181 residents (62%) returned a follow-up questionnaire measuring symptoms, spray-avoidance behavior, and the perceived effect of the spray program on health. Results: The number of symptoms reported after the spray was most closely related to the number of symptoms reported at baseline (&bgr; = 0.40, p = .0001). Higher levels of modern health worries (&bgr; = 0.23, p = .001) and baseline symptoms (&bgr; = 0.17, p < .05) were associated with a higher number of symptoms being attributed to the spray program. Modern health worries also predicted avoidance behavior during the spraying times (&bgr; = 0.32, p = .001) and the belief that the health of participants and the health of their children and pets was affected by the spray (all p < .01). Conclusion: Worries about aspects of modern life affecting health can strongly influence the attribution of symptoms and beliefs about health effects after environmental incidents. PANAS = Positive and Negative Affect Schedule.

Statistical guidelines for studies of the theory of reasoned action and the theory of planned behaviour

Abstract We identify potential problems in the statistical analysis of social cognition model data, with special emphasis on the theories of reasoned action (TRA) and planned behaviour (TPB). Some statistical guidelines are presented for empirical studies of the TRA and the TPB based upon multiple linear regression and structural equation modelling (SEM). If the model is tested using multiple regression, the assumptions of this technique must be considered and variables transformed if necessary. Adjusted R2 (not R2) should be used as a measure of explained variance and semipartial correlations are useful in assessing each components unique contribution to explained variance. R2 is not an indicator of model adequacy and residuals should be examined. Expectancy-value variables that are the product of expectancy and value measures represent the interaction term in a multiple regression and should not be used. SEM approaches make explicit the assumptions of unidimensionality of constructs in the TRA/TPB, assumptions that might usefully be challenged by competing models with multidimensional constructs. Finally, statistical power and sample size should be considered for both approaches. Inattention to any of these aspects of analysis threatens the validity of TRA/TPB research.

The Brussels Declaration: the need for change in asthma management

Asthma is a highly prevalent condition across Europe and numerous guidelines have been developed to optimise management. However, asthma can be neither cured nor prevented, treatment choices are limited and many patients have poorly controlled or uncontrolled asthma. The Brussels Declaration on Asthma, sponsored by The Asthma, Allergy and Inflammation Research Charity, was developed to call attention to the shortfalls in asthma management and to urge European policy makers to recognise that asthma is a public health problem that should be a political priority. The Declaration urges recognition and action on the following points: the systemic inflammatory component of asthma should be better understood and considered in assessments of treatment efficacy; current research must be communicated and responded to quickly; the European Medicines Agency guidance note on asthma should be updated; “real world” studies should be funded and results used to inform guidelines; variations in care across Europe should be addressed; people with asthma should participate in their own care; the impact of environmental factors should be understood; and targets should be set for improvement. The present paper reviews the evidence supporting the need for change in asthma management and summarises the ten key points contained in the Brussels Declaration.

Culture and Health: UCL- Lancet Commission.

Planned and unplanned migrations, diverse social practices, and emerging disease vectors transform how health and wellbeing are understood and negotiated. Simultaneously, familiar illnesses—both communicable and non-communicable—continue to affect individual health and household, community, and state economies. Together, these forces shape medical knowledge and how it is understood, how it comes to be valued, and when and how it is adopted and applied. Perceptions of physical and psychological wellbeing differ substantially across and within societies. Although cultures often merge and change, human diversity assures that different lifestyles and beliefs will persist so that systems of value remain autonomous and distinct. In this sense, culture can be understood as not only habits and beliefs about perceived wellbeing, but also political, economic, legal, ethical, and moral practices and values. Although culture can be considered as a set of subjective values that oppose scientific objectivity, we challenge this view in this Commission by claiming that all people have systems of value that are unexamined. Such systems are, at times, diffuse, and often taken for granted, but are always dynamic and changing. They produce novel and sometimes perplexing needs, to which established caregiving practices often adjust slowly. Ideas about health are, therefore, cultural. They vary widely across societies and should not merely be defined by measures of clinical care and disease. Health can be defined in worldwide terms or quite local and familiar ones. Yet, in clinical settings, a tendency to standardise human nature can be, paradoxically, driven by both an absence of awareness of the diversity with which wellbeing is contextualised and a commitment to express both patient needs and caregiver obligations in universally understandable terms. We believe, therefore, that the perceived distinction between the objectivity of science and the subjectivity of culture is itself a social fact (a common perception). We attribute the absence of awareness of the cultural dimensions of scientific practice to this distinction, especially for macrocultures and large societies, which define only small-scale, microcultures as cultural. We recommend a broad view of culture that embraces not only social systems of belief as cultural, but also presumptions of objectivity that permeate views of local and global health, health care, and health-care delivery. If the role of cultural systems of value in health is ignored, biological wellness can be focused on as the sole measure of wellbeing, and the potential for culture to become a key component in health maintenance and promotion can be eroded. This erosion is especially true where resources are scarce or absent. Under restricted and pressured conditions, behavioural variables that affect biological outcomes are dismissed as merely sociocultural, rather than medical. Especially when money is short, or when institutions claim to have discharged fully their public health obligations, blame for ill health can be projected onto those who are already disadvantaged. As a result, many thinkers in health-care provision across disciplines attribute poor health-care outcomes to factors that are beyond the control of care providers—namely, on peculiar, individual, or largely inaccessible cultural systems of value. Others, having witnessed the ramifications of such thinking, argue that all health-care provision should, rather, be made more culturally sensitive. Yet others declare merely that multiculturalism has failed and the concept should be abandoned, citing its divisive potential.1 Irrespective of who is blamed, failure to recognise the intersection of culture with other structural and societal factors creates and compounds poor health outcomes, multiplying financial, intellectual, and humanitarian costs. However, the effect of cultural systems of values on health outcomes is huge, within and across cultures, in multicultural settings, and even within the cultures of institutions established to advance health. In all cultural settings—local, national, worldwide, and even biomedical—the need to understand the relation between culture and health, especially the cultural factors that affect health-improving behaviours, is now crucial. In view of the financial fragility of so many systems of care around the world, and the wastefulness of so much of health-care spending, a line can no longer be drawn between biomedical care and systems of value that define our understanding of human wellbeing. Where economic limitations dictate what is feasible, socioeconomic status produces its own cultures of security and insecurity that cut across nationality, ethnic background, gender orientation, age, and political persuasion. Socioeconomic status produces new cultures defined by degrees of social security and limitations on choice that privilege some people and disadvantage others. Financial equity is, therefore, a very large part of the cultural picture; but it is not the entire picture. The capacity to attend to adversity—to believe that one can affect ones own future—is conditioned by a sense of social security that is only partly financial. In this Commission, we review health and health practices as they relate to culture, identify and assess pressing issues, and recommend lines of research that are needed to address those pressing issues and emerging needs. We examine overlapping domains of culture and health: cultural competence, health inequalities, and communities of care. In these three domains, we show how inseparable health is from culturally affected perceptions of wellbeing. After examination of these key domains, we identify 12 findings in need of immediate attention: Medicine should accommodate the cultural construction of wellbeing • Culture should be better defined • Culture should not be neglected in health and health-care provision • Culture should become central to care practices • Clinical cultures should be reshaped • People who are not healthy should be recapacitated within the culture of biomedicine • Agency should be better understood with respect to culture • Training cultures should be better understood • Competence should be reconsidered across all cultures and systems of care • Exported and imported practices and services should be aligned with local cultural meaning • Building of trust in health care should be prioritised as a cultural value • New models of wellbeing and care should be identified and nourished across cultures We believe that these points are imperative to the advancement of health worldwide and are the greatest challenges for health. Together, they constitute an agenda for reversal of the systematic neglect of culture in health, the single biggest barrier to advancement of the highest attainable standard of health worldwide.

Factors affecting uptake and adherence to breast cancer chemoprevention: a systematic review and meta-analysis

In this systematic review of studies investigating decision-making in the context of breast cancer preventive therapy, we observed low uptake of all agents and poor long-term persistence. Our meta-analysis including over 21 000 women demonstrated that only 1 in 6 eligible women decided to take preventive therapy. Persistence for 5 years was low, limiting the preventive effect in these women.