The International Journal of Pharmacy Practice 2006; Supplement 2 B5

IJPP 2006, 14: B5–B7© 2006 The Authors

From pharmacy to psychology and back again: researching the psychology of medicines usage and implications for pharmacy practice Professor Rob Horne

The lecture summarises a programme of research into medicinesusage applying scientific principles to understanding themedication-related behaviour of patients (adherence) andpractitioners (prescribing). The research questions weregenerated from pharmacy practice and addressed through theapplication of theories and methods derived from healthpsychology and other behavioural sciences. This work hasimproved our understanding of patient and physician perspec-tives of medicines and contributed to the development of theoryand methodology in health psychology. More importantly, ithas implications for the pharmacy practice now and in thefuture. The narrative of the research programme will illustratehow the scientific principles acquired during my pharmacydegrees were applied to researching questions of patient behav-iour and highlight the benefits of cross-disciplinary research.

The lecture will summarise the findings of a research pro-gramme which began in 1992 as a part-time PhD at GuysMedical School (now King’s College London) supported by aDepartment of Health Pharmacy Practice Research EnterpriseAward and initiated while I was Principal Pharmacist atBrighton General Hospital. This work, supervised by ProfessorJohn Weinman, was one of the first systematic investigations ofthe nature, determinants and effects of patients’ beliefs aboutmedicines across a range of chronic illnesses.

My work is based on the premise that the rate-limiting stepbetween the development of effective medicines and goodhealth outcomes is behaviour: the behaviour of clinicians, interms of prescribing, and the behaviour of patients, in termsof medicine taking. The impetus for my research came from a decade of practiceas a clinical pharmacist in London and Brighton. The practice ofclinical pharmacy has always been essentially about influencingbehaviour (of prescribers and patients). The original aim ofclinical pharmacy was deceptively simple: ‘to ensure that theright drug was received by the right patient in the right dose at

the right time’. However this meant a sea change in the wayin which pharmacy was practised in hospitals with pharmacistsemerging from the basement onto the ward. It represented achange from a product focus to a patient focus, with pharmacistsbecoming involved in discussions with clinicians and nursesabout the appropriate therapy for individual patients. Butoften, there was a forgotten figure in this: the patient.

Clinical pharmacy was practised on behalf of the patientbut most of our efforts were targeted before the patient got themedicine. This remains a significant limitation. In affluentcountries, like the UK, most of the healthcare resources aretargeted to the management of chronic diseases such as cardio-vascular disease, diabetes and asthma. It is now recognisedthat good outcomes depend as much on self-management ason good medical care and for most of these conditionsself-management hinges on the appropriate use of medicines.

In the UK, medicines account for approximately 11% ofthe NHS budget, the single largest source of expenditureabove staff. But, it has been estimated that over one-third ofprescribed medicines are not taken as directed. If we assumethat the prescription was appropriate, this represents a loss toboth the patient and the healthcare system. Moreover, effectivesolutions seemed elusive with systematic reviews of adherenceinterventions showing that few were effective and then withonly short-lived benefits. There is a need for innovativeapproaches to the problem.

One of the main reasons for the lack of efficacy of previ-ous adherence interventions is that they were not patient-centred enough. They generally adopted a ‘one-size fits all’approach and failed to consider both the practical and per-ceptual barriers to taking medication. This is problematicbecause non-adherence may be intentional as well as uninten-tional. Unintentional non-adherence is the result of practicalbarriers such as problems of memory, dexterity, accessingprescriptions, cost, competing demands, etc. Intentionalnon-adherence occurs when the patient decides not take themedication prescribed, in response to perceptual barriers suchas beliefs, attitudes and expectations.

The main aim of my research programme was to investi-gate perceptual barriers to adherence. Previously, research

Overview

Origins of the research programme in a Pharmacy Enterprise Award

The clinical problem and background to the research

Patients’ beliefs about medicines as determinants of adherence: development of assessment tools and explanatory framework

University of Brighton, UK

Rob Horne

B6 The International Journal of Pharmacy Practice 2006; Supplement 2

into medication adherence was hampered by a lack ofvalid and reliable methods for assessing the salient beliefsinfluencing patients’ motivation to start and continuemedication. To progress further we needed to identify themain themes underpinning people’s beliefs about medi-cines and to find a valid and reliable way of quantifyingthem.

The first step was to see whether the commonly expressedbeliefs about prescribed medicines could be summarisedunder simple core themes. My investigation of medicationbeliefs began by exploring the principal components underlyingrepresentations of prescribed medication, derived from inter-views with patients and from the small number of publishedqualitative studies. This work, involving over 4000 patientsfrom a range of chronic illnesses, suggested that people had‘common-sense’ beliefs, not just about specific medicinesprescribed for a particular illness but also more generalbeliefs about pharmaceuticals as a whole. These generalbeliefs influence people’s initial orientation towards prescribedmedicines.

Further analyses showed that, although patients’ ideasabout medicines are often complex and diverse, many of thebeliefs relating to specific prescribed medication could begrouped under two categories: perceptions of necessity orpersonal need for the treatment, and concerns about negativeeffects. Subsequent studies conducted in the UK and abroadshowed that this simple necessity–concerns frameworkexplained non-adherence in a range of chronic illness samplesincluding asthma, renal dialysis and post-transplantation,coronary heart disease, diabetes, HIV/AIDS, arthritis, inflam-matory bowel disease and cancer as well as mental healthproblems such as depression and bipolar disorder. In all ofthese studies, non-adherence was related to the way in whichpatients judged their personal need for the prescribed medica-tion relative to their concerns about the potential adverseeffects of taking it.

Moreover, medication concerns were not just relatedto the experience of side-effects but were also based onmore abstract beliefs about the potential dangers of medi-cines such as accumulation, long-term effects anddependence.

The consistency of findings across types of illness demon-strated the utility of the necessity–concerns framework asa generic model for operationalising the key treatmentbeliefs influencing adherence. This created the potentialfor clinical application, in that the framework could poten-tially be used by practitioners to help them elicit salientpatient perspectives and as a basis for discussion to facili-tate optimal adherence to appropriately prescribed medica-tion. However, to be of use in practice, we needed a betterunderstanding of the origins of necessity beliefs and con-cerns. This was essential to develop evidence-based meth-ods for helping patients to form realistic evaluations oftheir personal need for treatment, and to prevent misplacedconcerns.

In parallel with this work assessing beliefs about medicines,I was involved in the development of methods for assessingother relevant aspects of patients’ experience of medicines,including measures of their beliefs about illness, satisfactionwith information about medicines and treatment empowerment.These scales facilitated further studies examining the ways inwhich patients evaluate medicines and the origins of necessitybeliefs and concerns.

These studies provided clear and consistent evidence that,although they were often not concordant with the medicalview, patients’ necessity beliefs and concerns were derivedfrom ‘common-sense’ beliefs about the illness and their inter-pretation of symptom experiences. They were also related tomore general beliefs about medicines as a whole (socialrepresentations). These findings were consistent with psycho-logical theories of illness behaviour, and resulted in theincorporation of medication beliefs into a wider theoreticalmodel (Leventhal self-regulatory theory).

Studies of patient perspectives of their illness and treatmentproduced consistent findings across illness samples, showingthat decisions about medication usage are often based onbeliefs that, although logically consistent from a common-sense perspective, may be based on misconceptions andmistaken premises. This work has coincided with a change inthe zeitgeist in healthcare favouring greater patient involvementand choice – the concordance and medicines partnershipinitiatives are manifestations of this. The research findingshave implications for how these ideals might be put into practiceand for how pharmacists might enhance their ‘near to patient’skills, and this will be discussed.

The findings and theoretical framework derived from theresearch described above formed the basis for recent pilotintervention studies in asthma and renal disease. Workingwith the Division of Psychology at the Institute of Psychiatry,University of London, I have recently applied the models tounderstanding prescribing behaviour and to explainingother treatment-related behaviour such as attendance at reha-bilitation classes following myocardial infarction and diabeticfoot care.

In collaboration with the Department of Policy and Prac-tice at the School of Pharmacy, University of London (DPP-SOP), I have applied this research in the development of acommunity pharmacy-based intervention to identify medi-cation- related problems and facilitate optimal adherencewith promising results. Applications have received RoyalPharmaceutical Society of great Britain (RPSGB) Pharma-ceutical Awards (winner and runner up in 2003) and havebeen used to develop communication skills packages forcommunity pharmacy and in the teaching of communicationskills for pharmacy students and graduates. This work isongoing.

The ‘common-sense’ origins of medication necessity beliefs and concerns

Implications for practice

Current and future work

The International Journal of Pharmacy Practice 2006; Supplement 2 B7

Further collaboration with DPPSOP and King’s CollegeLondon resulted in a recent scoping exercise for the NHSNational Co-ordinating Centre for Service Delivery andOrganisation (NCCSDO). This provided a conceptual map ofthe areas of compliance, concordance and adherence, andidentified research priorities. A key finding was the need forthe development of theory-based interventions tailored to

the needs of individuals and informed by evidence of theantecedents of medication-taking behaviour. I am lookingforward to continuing to work with colleagues in pharmacy,medicine, psychology and other disciplines, to continue theapplication of behavioural medicine in pharmacy and toinform improvements in the quality of professional servicesdesigned to help patients get the best from medicines.