How reflections on concordance in mental health can affect research and clinical practice in adherence
In this article I will attempt to draw together previous literature, research findings and clinical observations in the area of concordance. I will draw on examples from mental health, because this is the area I have concentrated on in my own research. Indeed mental health is an ideal area in which to lay bare some of the inconsistencies and problems in carrying out research and clinical practice in adherence. However, the problems and observations reported are relevant to other areas of health care and it is striking how similar the attitudes to taking medicines are in people with mental health problems and people with other health problems.1
Research in the area of medicine taking has been carried out for many years. However the quality of the research has not always been high and often research findings are not translated into clinical practice. In addition to the erroneous assumptions that plague previous research papers, research in the area of adherence is fraught with difficulties, as outlined below.
Haynes et al2 first defined compliance as: “The extent to which a person’s behaviour in terms of taking medications, following diets, or executing lifestyle changes, coincides with medical or health advice.”
The term “compliance” has been criticised for being paternalistic because it assumes that health professionals are correct in the advice they offer and that not taking medicines is irrational. To take such a one-sided view is clearly unhelpful. It is logical that health professionals should have such a paternalistic view to medicine-taking. Even before people start training as health professionals they are more likely than the general population to endorse the biomedical model of health. Horne et al3 showed that pharmacy students are more likely to believe that medicines are beneficial and less likely to perceive medicines are harmful than students from other disciplines. Throughout training the benefits of medication are emphasised and adverse effects of treatment are often seen as a minor discomfort that should be borne quietly by patients.
Further definitions have been offered and the term “adherence” has been suggested but since this is defined as “to stick to exactly” it is difficult to see how it furthers thinking. The most positive move in this area was the setting up of the Concordance Working Party, which suggested the term “concordance” and set a definition which incorporated a two-sided approach to medication: respecting the consumer’s view and acknowledging that the consumer’s view should be respected even if he or she made choices that sometimes appeared unhealthy. This was a great step forward but, unfortunately, evidence from some research papers and teaching has shown that some people have substituted the word “concordance” for “compliance” in research papers and lecture notes without fully endorsing the true spirit of concordance.
There is no gold-standard, valid and reliable measure of medicine-taking behaviour. Various scales have been produced such as the “Beliefs about medicines” questionnaire,4 which is a valid and reliable 18-item scale.
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Citation: The Pharmaceutical Journal URI: 10986711
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