Medicines Management
Issue no 3, p9-11
May/June 2002
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Medicines Management |
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Features |
Can we help patients keep resolutions?
A friend of mine works in an office on the sixth floor of his company's building. He takes the lift each morning and throughout the day when he has meetings elsewhere in the building. He tells me he knows the precise number of steps from the building's entrance to the sixth floor — there are 108 — because he climbs them every year on the first working day in January. After a few days (and for the rest of the year) he resorts to the lift, his New Year's resolution to "walk the stairs more often" long forgotten. My friend is not unique — the bulging lift and the empty stairwell are testament to that — and most of us fail to do some of what we intend. How different is this to someone who wants to eat more healthily or remember to take his/her medicines every day? What should people, like my friend, do differently next January to break the pattern of failed resolutions and instead take the stairs more often? Recent psychological studies suggest that forming an implementation intention would help, because it is a powerful means of turning an intention to do something into an actual behaviour.1 An implementation intention is specific, such as "I'm going to climb the stairs when I first arrive for work" rather than the more general resolution of "I'm going to climb the stairs more often". The evidence suggests that such strategies can also help to maintain a continued link between intentions and behaviour, so that my friend will climb the stairs into February, March and beyond. If implementation intentions do work to increase the amount of intended behaviours that actually happen then they could be applied to taking medicines. Medicine-taking is a behaviour, just as eating more fruit, going to the gym or climbing the stairs are behaviours. Impact on medicine-taking The effects of implementation intentions are being tested in a University of Leeds study funded by the Northern and Yorkshire Regional Health Authority. The study is recruiting people taking once daily medicines for cardiac conditions to see whether those who form an implementation intention take more of their medicine as prescribed in the follow-up period. The background to implementation intentions lies in an established theory in social psychology called the Theory of Planned Behaviour.2 The theory says that the best predictor of an action is the intention to carry it out. No surprises so far. The clever bit lies in understanding what underpins the intention to carry out an action. The theory of planned behaviour proposes that there are three components to the intention. The first is having a positive attitude to the action ("climbing the stairs is a good thing to do"). Second is having a supportive subjective norm ("most people who are important to me think that I should take the stairs more often"). The third is having greater perceived behavioural control ("For me to take the stairs would be easy"). This theory has received considerable support in many studies in a wide range of behaviours, from breast feeding to eating more vegetables, from using condoms to attending clinic appointments. Systematic reviews show that the three factors of attitudes, subjective norms and perceived behavioural control explain around 45 per cent of the variance in intentions.3 That is, they are about half-successful in making the link between the three factors and people's intention to carry out an action. However, the link between the intention and the behaviour is imperfect, as my friend's example shows. Meta-analysis of data from many studies suggests that intentions rarely explain more than 50 per cent of the variance in behaviour.4 So, is the glass half-empty or half-full? The statistical link between intentions and behaviours is consistent throughout many studies and is far greater than chance — there does seem to be a link between intending to do something and doing it. Some of the missing link might be due to problems in the studies themselves — measurement error could explain some of the missing variance, for instance. But this is unlikely to be the whole story — it seems certain that other factors intervene and break the link between the intention and the behaviour. Perhaps this is why non-compliance in medicine-taking is so high — only around 50 per cent of medicines are taken as prescribed — with the resultant prolonging of illness and its associated costs (additional prescriptions, visits to the GP and absence from work). Forming an implementation intention is said to work because it makes the goal we want to achieve (that is, the behaviour) both specific and in the near future. Current research in this area suggests that forming and stating an intention to carry out the desired activity at a particular time and place, preferably in a situation when we have most control over the outcome, is likely to be effective. Intentions in medicine-taking With people taking medicines, an effective intention might be "I'm going to take my blood pressure tablet each morning after cleaning my teeth". Compare this with the general intention to "…take my blood pressure tablets more often". Patients' non-compliance with medicine taking can usefully be categorised as either intentional or non-intentional. Intentional non-compliance is generally thought to happen because of the patient's beliefs about their illness and its treatment, whereas non-intentional non-compliance results because of errors such as forgetting. Implementation intentions are said to work mostly on non-intentional non-compliance, because they can act as an aid to memory — they offer a cue or reminder to carry out the behaviour. However, there is also a suggestion that they can be effective in overcoming intentional non-compliance. This is thought to happen because making a strategy strengthens the intention to comply, perhaps because it is a form of declaration of commitment to "doing" the behaviour. Aims of Leeds study The study in Leeds is testing the effects of implementation intentions on medicine-taking behaviour by using a randomised controlled trial design. There are four arms in the trial, two control and two intervention groups. In one control group patients are recruited to the study and receive follow-up data collection only. Patients in the second control group are recruited and complete a Theory of Planned Behaviour questionnaire to assess the effect of the three components (attitudes, subjective norms and perceived control) on outcome. Patients in the two intervention groups also complete the questionnaire and are followed-up, but additionally form an implementation intention. The difference between the two intervention groups is that while patients in one group form their own strategy, the others have it formed for them by the practice nurse or researcher. This comparison should provide new information, since it is not clear from the existing research whether implementation intentions formed by another person are as effective as those we form for ourselves. Patients in the study Patients from several practices in South Leeds PCG are being recruited to the study by the practice nurse or researcher. The patients are a mixture of those starting a new cardiac medicine and those who have been taking the medicine for some time. The aim is to recruit 360 patients in total and all patients are followed up by telephone data collection at seven, 28 and 90 days after recruitment. The primary outcome in the trial — compliance with medicine as prescribed — is being assessed by a combination of questionnaires and pill count. With 360 patients recruited the trial should be big enough to test whether self-formed implementation intentions are more effective than those given to us by someone else. More importantly, the trial will test whether the promise shown in the early strategies studies has been fulfilled. For example, one study showed that women who formed implementation intentions were more likely to perform breast self-examination than those who did not. Another found a similar effect on attendance for cervical cancer screening.5,6 Of more relevance to medicine-taking, another study has reported a significant increase in the use of daily Vitamin C tablets among people who had formed a strategy.7 At ten days after recruitment the difference between the implementation intention group and the non-intention group was 4 per cent (94 per cent versus 90 per cent) but by three weeks the difference had grown to 10 per cent (92 per cent versus 82 per cent). This suggests that forming an implementation intention might have continued effects on behaviour — giving hope to my resolution-breaking friend. So, the next time you enter a building and find yourself alone in the lift, take a peek into the stairwell. If it is full of people puffing up the stairs you will know that the implementation intentions squad has paid a visit. Members of the Leeds Implementation Intentions in Medicines
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