FEATURE1 October 2005

Doctor who?

Case Study: Patient non-compliance is a major issue in the healthcare sector. Vikki Schwebel looks at how research can aid understanding

Many patients don’t take their medicines as prescribed, even when failing to do so could prolong diseases or have life-threatening consequences. It’s human nature: some people are generally less compliant than others.

But the reasons behind this failure can vary greatly. Some fail to recognise the importance of their treatment regime, others choose to ignore it. Moreover, taking medicines often means that patients need to break old habits and acquire new ones, which requires focus and effort – sadly, not always the strongest of human traits.

Science of compliance
Whatever the reason, though, the first step to improving compliance must surely be to improve our understanding of patients’ attitudes towards disease management.

The fact is that across patients, diseases and even countries, there are a relatively small number of different patient ‘mindsets’ in terms of attitude to therapy. By understanding these mindsets and classifying patients according to ‘attitudinal type’, it may be possible to create different therapeutic strategies to suit the different mindsets. This, in turn, may improve compliance.

Battery pharma
Specialist agency, Healthcare Research Worldwide (HRW) has developed a battery of 20 attitudinal statements covering patients’ attitudes to disease management. These have emerged out of consultation with several major pharmaceutical companies and are under-pinned by HRW’s own qualitative research with patients.

That research was conducted online using patients provided by Bloomerce and the specialist programming skills of qubiq-online. In total, over 400 patients from France, UK and US took part. Each of these was asked to respond in the context of an ongoing chronic condition and/or a recent acute condition.

Patients were shown the attitudinal statements in randomised lots of four and asked to decide which of the four was of greatest and least importance to them in the context of their condition (a technique known as ‘best/worst scaling’). This yielded 717 patient responses in total.

Addressed to the nines
Initially, it seemed that there were wide differences in attitudes across patients and conditions. However, HRW’s Attitudinal Segmentation identified just nine underlying points of view – or attitudinal segments – covering almost 90% of responses.

Attitudinal Segmentation identifies patients who share a common view about which attitudinal statements have the strongest positive and negative influence on the way they feel about disease management and therapy. These nine ‘mindsets’ represent the true, underlying ‘structure’, in terms of attitudes to disease management, some of which reflect very different points of view.

Beware the obvious
The other interesting point that was immediately apparent was that the overall importance of each attitudinal statement, when calculated across all 717 responses, bore very little resemblance to the main attitudinal drivers across the nine segments. For example, ‘Being made fully aware of how the treatment will help my condition’ is, on average, rated most important overall.

In reality, this is an important driver in just one segment, comprising 9% of patient responses. It is rated most important overall because no sensible patient would consider it irrelevant or low priority. However, for the vast majority of patients, it is not a strong positive driver.

Conversely, many of the other constructs are very strongly polarising, depending both on the patient’s condition and attitude, so when ‘averaged’ across patients and conditions, they (incorrectly) seem less important overall.

True to life
These initial observations clearly demonstrate the importance of segmentation in attitudinal studies. Experiences from everyday life tell us that individuals have radically different points of view on almost any subject. It follows that research that lumps everybody together to establish overall rank order of importance is bound to be misleading (and, in this case, profoundly so).

That said, there are some general observations worth mentioning, not because they have high overall mean importance ratings, but because they are strong attitudinal drivers across several segments.

Nature’s way
The notion of using natural remedies as an alternative to conventional medicine, for example, is heavily rejected across six attitudinal segments (amounting to 74% of patient responses). However, two segments (representing 10% of patient responses) are supportive.

One of these segments, which has been labelled ‘Natural remedy extremists’ ( 5%), is very strongly driven by the idea of using natural remedies and changes to lifestyle and/or diet and strongly rejects the idea of pharmaceutical medicines and the involvement of healthcare professionals (HCPs). The ‘Natural Remedy Extremist’ segment comprises patients with a wide variety of conditions but there is a prevalence of food intolerances, arthritis and polycystic ovaries, and it has a female and UK bias.

Gentle folk
The second segment inclined towards natural products (also 5%) is much less radical and more open to medical opinion. HRW has named this segment the ‘Gentle listeners’. Again, it comprises patients with a variety of diseases, although chronic conditions – such as arthritis, rheumatism, skin conditions, stress, high cholesterol, strokes and heart attacks – are especially prevalent. There is also a preponderance of females and French patients.

However, despite the fact that these two segments clearly believe in natural remedies, it seems that natural remedies have much to do to convince the vast majority of patients of their efficacy.

Against all odds
Indeed, the idea of choosing a treatment that goes against the HCP’s advice is rejected by six of the attitudinal segments (amounting to almost 60% of patient responses). For these people, the notion that ‘doctor knows best’ still prevails. This may not be surprising.

What is perhaps more surprising, however, is that three segments, amounting to 30% of patient responses, actually endorse the idea of going against the HCP’s recommendation. It would be interesting to track this statistic over time!

High maintenance
Of the six segments mentioned above, two in particular seem to demand a very high level of HCP involvement, albeit for different reasons. This first has been called the ‘Emotionally dependent’ because of the very high level of involvement and support expected from HCPs. They represent 14% of patient responses. Amongst these, the incidence of chronic conditions is again relatively high – more diabetes, asthma, heart disease, stress and depression – and they are predominantly older ( 41+) and British.

The other ‘demanding’ segment is labelled ‘Controllers’ ( 9%), largely because they want to know everything, from how the treatment will help their condition, how long the ailment will last, and the probability of recovery, to clear instructions on how to take the medicine and any likely side effects. They certainly don’t want to self-diagnose or self-prescribe. Medically, these patients are quite similar to the ‘Emotionally dependent’, in that the incidence of chronic conditions is relatively high and they tend to be older ( 51+).

Taken together, the ‘Emotionally dependent’ and the ‘Controllers’ amount to 23% of patient responses, suggesting a very significant burden for HCPs.

Compliant procedure
The fifth attitudinal segment is known as the ‘Quietly compliant’. These account for 11% of patient responses and tend to represent people with chronic conditions such as high cholesterol, hypertension and the like. These patients tend to be males in the mid-age band ( 31-40 ). They are probably the most willing of all to take a longer term view and don’t look for immediate relief. They prioritise staying with treatment after the symptoms have gone, even if it has side effects. The ‘Quietly compliant’ don’t want to self-treat or go against HCP opinion. However, otherwise they seem very undemanding of HCP involvement.

The next two attitudinal segments place more emphasis on getting the necessary drugs/prescription to treat the condition. The largest of these two segments has been named the ‘Acute – just give me the drugs’ ( 13%). The other is known as the ‘Chronic – just give me the drugs’ ( 7%).

Repeat business
The ‘Acutes – just give me the drugs’ want a prescription to relieve the immediate condition and clear instructions on how to use the medication effectively. It seems that these patients want to see an HCP at the outset, they want a prescription and they don’t want to see the HCP again in order to get a repeat prescription. They just want to be given the drugs and left to get on with it!

Similarly, the ‘Chronic – just give me the drugs’ segment prioritise being able to get repeat prescriptions without needing to see a HCP every time way above any other positive driver. The only other statement with anything like the same impact is their reluctance to even consider natural products.

These patients represent a whole swathe of chronic conditions. Perhaps because of this, they are quite well disposed to HCP involvement and they certainly don’t want to self-prescribe. For similar reasons, they’re also willing to take a long-term view about compliance.

The eighth segment ( 5%) is labelled ‘Opinionated self-prescribers’. These people are generally suffering from a spectrum of acute conditions, including coughs, colds, hay fever, headaches, and the like. They are very heavily influenced by the desire to get immediate relief and to minimise the impact on daily life. Consequently, they neither want advice nor involvement from HCPs.

The final segment, at 20%, is the biggest attitudinal segment among the nine. They are similar in outlook to the ‘Opinionated self-prescribers’, except that their views are much less strongly held. These are just ‘everyday’ people with ‘everyday’ acute conditions who just want relief from the symptoms so that they can get on with their everyday lives. For this reason, we’ve named them ‘Everyday self-prescribers’. Typically, they’re not looking for HCP involvement and don’t want to treat the condition via diet or natural products.

Back to basics
But, to get back to the original question, what does this mean in terms of compliance?

The size of the attitudinal segments is, in part, consequent upon the proportion of patients with acute and/or chronic conditions. However, based on past experience, it is very likely that these nine distinct segments will comprehensively and accurately characterise the different attitudinal mindsets of the body of patients at large.

For the future, it would be relatively easy to ‘type’ any subsequent patient as belonging to one or other of the nine mindsets (for a particular condition) by asking them to react to the most differentiating of the 20 attitudinal statements used in this study.

By doing this, we could then learn more about the attitudes, beliefs and behaviours of these nine mindsets and, consequently, start to think about ways in which therapeutic regimes could be designed and presented differently, in order to improve compliance.

Vikki Schwebel is research director at Healthcare Research Worldwide

October | 2005