Simple Sketches Could Provide Insights into Factors Affecting Treatment Adherence
Drawings of stick men, similar to those doodled in school books around the world, could be one way of informing the content of patient adherence and support programmes (PSPs) for osteoporosis patients, according to new research.
The study, led by Sarah Jane Besser at King’s College London, used a combination of in-depth interviews and patient drawings to gain an understanding of patients’ perception of both their condition and also treatment – but it was the drawings that revealed the most surprising results, says co-author of the study, Professor John Weinman, Professor of Psychology as Applied to Medicine at King's College and Head of Health Psychology, Europe at Atlantis Healthcare.
“Rather innovatively, Besser asked patients to draw what they thought both healthy and damaged bone looked like, and stick men to represent the posture of people with osteoporosis,” explains Prof Weinman.
The drawings revealed a huge variation in patient understanding of the disease. “Many drew the healthy and damaged bone in the same way, or drew damaged fragments, rather than damage to the core,” says Prof Weinman.
Naturally, a patient’s understanding of their condition will influence the way they manage their illness, including how they take their prescribed treatment.
The impact of osteoporosis
Osteoporosis is a significant clinical and public health concern, affecting around 50 per cent of women and 30 per cent of men over 65. Bone mineral density is reduced, leaving patients vulnerable to fractures – which are one of the most common causes of patient disability and a major contributor to medical costs worldwide. The growing burden on the healthcare system and the problem of patient adherence to treatment, were recently hot topics at the The European Congress on Osteoporosis and Osteoarthritis (ESCEO13-IOF), in Rome (17-20 April, 2013).
During the congress Prof. John Kanis, President of the International Osteoporosis Foundation highlighted the financial impact of osteoporosis. “Every person in Europe pays an “osteoporosis tax” of £75 to cover the direct costs of managing the disease.”
“But I don’t feel ill…” – overcoming the barriers to adherence
“The great difficulty is that osteoporosis is a very serious condition but it’s a largely “hidden” disease for many sufferers, as there are no obvious symptoms until a fall or fracture occurs. There’s a massive vulnerability factor,” explains Prof Weinman.
Effective treatments are available on prescription but adherence is low. “Treatments can have unpleasant side effects and because the disease is often “symptomless” as far as the patient is concerned, they don’t feel it’s worth putting up with them,” says Prof Weinman. “Even when patients have had falls or fractures, many don’t associate them with their condition – they put it down to old age, eyesight or an accident – they don’t see the complications are caused by their osteoporosis.”
Applying patient drawings in practice
The challenge for PSPs is creating patient understanding of this vulnerability – and Besser’s patient drawings opened up potential new scope for doing this. “Perhaps the most surprising result came from the emotional response the drawings elicited,” explains Prof Weinman. “When interviewed with the questionnaire, many reported that their condition didn’t have a marked effect on them emotionally. But when they drew the stick men illustrating posture – some quite bent over – many became quite upset. Drawing seemed to create a more concrete awareness, bringing out the emotions of patients in a way that words could not.”
Over the last decade, health psychologists have become increasingly interested in the use or patient drawings. A pioneering studyby Keith Petrie, University of Auckland, asked heart attack patients to draw how they felt their heart looked before and after their heart attack. Petrie was able to measure the perceived damage and quantify it to predict recovery outcomes – in many cases these were as effective, if not more so, than medical markers.
Besser is now trialing a new PSP to help patients better understand the way in which treatment can directly improve bone structure and function. The educational material uses images showing changes in bone density, and makes directs links to patient vulnerability. The program is highly personalized, working from each patient’s beliefs.
The benefits of psychological patient support?
“This highly individualized intervention approach is more time consuming at first, but ultimately I believe it will have huge savings downstream,” says Prof Weinman. “It’s more about where the time is allocated. If the effort is made upfront to ensure patient understanding and address their particular concerns or misconceptions, then you don’t have the problem of them stopping treatment a month, six months, or a year down the line when their beliefs have become entrenched. This has better outcomes for the patient, but also for the healthcare system.”
The study also has implications for intervention design across other disease states. “I’m sure direct parallels can be drawn in similar conditions where treatment is largely preventative, like asthma, hypertension and stroke,” says Prof Weinman. “But I think it’s also for all conditions where adherence to medication is low, such as heart disease, rheumatoid arthritis and HIV.”
To get a better understanding of why patients don’t adhere to treatment, we need to know how illness affects people emotionally and behaviorally, as well as physically, says Prof Weinman. “Drawing can give us a unique insight by tapping into the emotional, as well as the cognitive, response,” he says. “We can use this tool to create highly personalized intervention programs – and a unique and effective way to offer support.”
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