The Role of Beliefs in The Role of Beliefs in Decisions about Decisions about

MedicationMedicationKathleen Mazor, EdDKathleen Mazor, EdD

HMORN CERTHMORN CERTMeyers Primary Care Institute, Meyers Primary Care Institute,

University of Massachusetts Medical School, University of Massachusetts Medical School, Fallon Community Health Plan and Fallon ClinicFallon Community Health Plan and Fallon Clinic

BackgroundBackground

For therapy to occur, the patient For therapy to occur, the patient must must accept accept the the recommendation to initiate recommendation to initiate medication.medication.

This step is often overlooked.This step is often overlooked. This session will focus on the role This session will focus on the role

that that beliefsbeliefs play in patients’ play in patients’ decisions to accept medication.decisions to accept medication.

Three Relevant StudiesThree Relevant Studies

The role of beliefs, The role of beliefs, communication and trust in a communication and trust in a hypothetical decisionhypothetical decision

The role of knowledge, beliefs, The role of knowledge, beliefs, communication and trust in communication and trust in initiating OP medicationsinitiating OP medications– Questionnaire studyQuestionnaire study– Interview studyInterview study

Accepting HTN Accepting HTN medication in a medication in a hypothetical situationhypothetical situation 210 lay people recruited from the 210 lay people recruited from the

community community QuestionnaireQuestionnaire

• Imagine yourself just diagnosed with Imagine yourself just diagnosed with HTN, you have this conversation with HTN, you have this conversation with your doctor…your doctor…

• Questions: would you accept Questions: would you accept medication, trust, doctor’s medication, trust, doctor’s communication, beliefs about communication, beliefs about medication and HTN.medication and HTN.

AnalysisAnalysis

Bivariate correlationsBivariate correlations Multivariate models predicting Multivariate models predicting

acceptanceacceptance

Results Results Best predictors of Best predictors of initiation…initiation… Trust in the physician.Trust in the physician. Perception that the physician has Perception that the physician has

communicated well.communicated well. Belief that medication is effective Belief that medication is effective

in treating HTN.in treating HTN. Belief that doctors do not Belief that doctors do not

prescribe unsafe medications.prescribe unsafe medications.

Initiation of Prescription Initiation of Prescription Medication for Medication for OsteoporosisOsteoporosis Women with recent bone density Women with recent bone density

study meeting WHO criteria for study meeting WHO criteria for OP, not treated in prior 6 months OP, not treated in prior 6 months

Mailed questionnaireMailed questionnaire• knowledge, beliefs, experiencesknowledge, beliefs, experiences

Electronic medical record review Electronic medical record review and pharmacy recordsand pharmacy records

ResultsResults

465 women invited to participate465 women invited to participate 271 returned survey (58%)271 returned survey (58%) 57% started prescription OP 57% started prescription OP

treatment within 3 months of treatment within 3 months of testingtesting

Women who do not start are more likely to agree…

I can take care of my OP without medications (26 vs 5)

There are better ways for me to treat my OP besides medications (45 vs 24)

I worry about the side effects of taking OP medication. (77 vs 57)

Women who do not start are more likely to agree… Medications often cause more problems

than they solve. (50 vs 31)

I prefer not to take medications. (61 vs 43)

Doctors are too quick to prescribe medications (46 vs 30)

Doctors often give medication when advice would be better. (40 vs 24)

Women who do start are more likely to agree… Taking OP medication is good for me.

(62 vs 37)

Medication can effectively treat my osteoporosis. (72 vs 49)

I worry about having OP. (72 vs 51)

Women who do start are more likely to agree…

Taking OP medication can help my bones become stronger. (77 vs 58)

Taking OP medication can help me stay independent. (66 vs 47)

Taking OP medication can help me stay active. (66 vs 48)

No difference or very small difference…

• My prescriptions sometimes cost more than I can afford.

• I think OP is a very serious disease.• I sometimes forget to take my

medications on time.• I worry about interactions between my

medications.

SummarySummary

More likely to accept med if …More likely to accept med if … Believe OP will be effective and Believe OP will be effective and

beneficialbeneficial

More likely to decline if..More likely to decline if.. Believe can prevent OP otherwiseBelieve can prevent OP otherwise Distrust medication, concerned Distrust medication, concerned

about side effects and problemsabout side effects and problems

Further exploration of Further exploration of acceptance of OP acceptance of OP medsmeds 35 in-depth qualitative 35 in-depth qualitative

interviewsinterviews• Women age 65 and olderWomen age 65 and older• Have had BMD testingHave had BMD testing• meet WHO criteria for OPmeet WHO criteria for OP

Focus on 3 decisions: accept, Focus on 3 decisions: accept, decline, discontinuedecline, discontinue

Preliminary FindingsPreliminary Findings

Analysis is currently underway…Analysis is currently underway…

Why women Why women acceptaccept treatmenttreatment

Believe medication will be helpfulBelieve medication will be helpful• I should take something because I want to I should take something because I want to

keep my bones as strong as possiblekeep my bones as strong as possible• I was glad to take it if it was going to help.I was glad to take it if it was going to help.• I don’t like taking prescription drugs, but I don’t like taking prescription drugs, but

obviously since my exercise and diet was obviously since my exercise and diet was not working, I had to do it ...not working, I had to do it ...

Why women Why women acceptaccept treatmenttreatment

Trust in their physicianTrust in their physician• if your doctor tells you that you have if your doctor tells you that you have

to, you more than likely listento, you more than likely listen• [I] took his word that this was what I [I] took his word that this was what I

should do…I do trust him. I feel should do…I do trust him. I feel comfortable and I don’t think that he comfortable and I don’t think that he would lead me in the wrong would lead me in the wrong direction. direction.

Why women Why women acceptaccept treatmenttreatment Awareness of the debilitating Awareness of the debilitating

consequencesconsequences– I see people that do have it and the I see people that do have it and the

way they’re bent way over due to way they’re bent way over due to the back problem and they’re in a the back problem and they’re in a lot of pain and it’s kind of scary. I lot of pain and it’s kind of scary. I visualize myself in five years, is that visualize myself in five years, is that going to be me?going to be me?

Why women Why women decline decline treatmenttreatment

• See medication as See medication as unnecessaryunnecessary• Like I said, I dance, I jump, I fall down, Like I said, I dance, I jump, I fall down,

I get up, I plant, I dig, I plant, I do I get up, I plant, I dig, I plant, I do everything I want. Don’t have a everything I want. Don’t have a problem. problem.

• … … my bones seem to be pretty good. my bones seem to be pretty good. I’ve fallen a few times and I’ve never I’ve fallen a few times and I’ve never broken a bone. I’ve never broken broken a bone. I’ve never broken anything.anything.

Why Why women declinewomen decline treatmenttreatment

Concerns about side effectsConcerns about side effects• I’d rather risk a fall, which could happen I’d rather risk a fall, which could happen

tomorrow or it could happen when I’m tomorrow or it could happen when I’m 80, rather than take something daily 80, rather than take something daily that has high risks of side effects.that has high risks of side effects.

• There’s all kinds of things that happen There’s all kinds of things that happen when you take this prescription when you take this prescription medicine…medicine…

Why women Why women decline decline treatmenttreatment

• Concerns about medication Concerns about medication precautionsprecautions• But if they say, You have to stand up, or But if they say, You have to stand up, or

you can’t lay down when you take these you can’t lay down when you take these pills, and I’m going, What is going on pills, and I’m going, What is going on here? Just how much does this involve? I here? Just how much does this involve? I don’t like that...And what is this stuff don’t like that...And what is this stuff anyway? Is it like plutonium? What is it? anyway? Is it like plutonium? What is it? Am I going to blow up if I lay down? Am I going to blow up if I lay down?

• you’re ingesting something that sounds you’re ingesting something that sounds pretty powerful to me … … I have no pretty powerful to me … … I have no problem standing, sitting, but I just even problem standing, sitting, but I just even think that precaution makes me leery.think that precaution makes me leery.

Why women Why women discontinue discontinue treatmenttreatment

Experience with side effectsExperience with side effects• I was sick. I went down in my bed. I was I was sick. I went down in my bed. I was

vomiting, and I don’t vomit.vomiting, and I don’t vomit.• I had side effects from this medication…I had side effects from this medication…

there was something in there that didn’t there was something in there that didn’t agree with me. agree with me.

• I started getting clicking of the jaw. Sort of I started getting clicking of the jaw. Sort of like a lockjaw type of thing. … after a like a lockjaw type of thing. … after a month or two, I stopped taking it because month or two, I stopped taking it because of that and it went away. of that and it went away.

Why women Why women discontinue discontinue treatmenttreatment

FearFear of side effects of side effects• ..I read an article about fosamax, ..I read an article about fosamax,

something about the jaw, it could cause a something about the jaw, it could cause a big problem there...when I read that, I said, big problem there...when I read that, I said, That’s it, I will never take them again.That’s it, I will never take them again.

• I had heard of a friend of mine who had I had heard of a friend of mine who had been taking fosamax for like ten years, she been taking fosamax for like ten years, she started losing her teeth. So I got kind of started losing her teeth. So I got kind of worried about that because that’s one worried about that because that’s one thing I don’t want to do is lose my teeth. thing I don’t want to do is lose my teeth.

Why women Why women discontinuediscontinue treatmenttreatment

Lack of reaction from prescriberLack of reaction from prescriber• But I got sick on it. So then he said, Well But I got sick on it. So then he said, Well

never mind, just don’t take anything. So that never mind, just don’t take anything. So that was that.was that.

• They’re overloaded and I guess with me They’re overloaded and I guess with me saying I wasn’t going to take it anymore he saying I wasn’t going to take it anymore he just said, Well that’s your decision, abruptly, just said, Well that’s your decision, abruptly, and that was that. and that was that.

• ……in November when I went and I told her I in November when I went and I told her I wasn’t taking it, she didn’t push me or say wasn’t taking it, she didn’t push me or say anything. She just wrote it on my chart.anything. She just wrote it on my chart.

Conclusions

Beliefs are important influences on decisions about medications

Belief in the need for the medication

Belief that the medication will help Belief that the medication is safe;

side effects unlikely or minimal

Conclusions

Don’t yet fully understand how beliefs function –impact is probably not constant across people, conditions, medications.

Don’t yet know how to change beliefs.

Next steps…

Better understanding of mental models– What affects perceptions of need? – What affects perceptions of safety?– What affects perceptions of benefit?

Strategies for changing beliefs– For physicians– Print/media/web materials

ReferencesReferences

Mazor KM, Fischer MA and Billings-Gagliard S. Initial Mazor KM, Fischer MA and Billings-Gagliard S. Initial Acceptance of Treatment with Antihypertensive Medication: The Acceptance of Treatment with Antihypertensive Medication: The Importance of Communication, Trust and Beliefs. Importance of Communication, Trust and Beliefs. Journal of Journal of Communication in Healthcare.Communication in Healthcare. 2008. 1(3). 311-323. 2008. 1(3). 311-323.

Yood RA, Mazor KM, Andrade SE, Emani S, Chan W, Kahler Yood RA, Mazor KM, Andrade SE, Emani S, Chan W, Kahler KH. Patients’ Decisions to Initiate Therapy for Osteoporosis: KH. Patients’ Decisions to Initiate Therapy for Osteoporosis: The Influence of Knowledge and Beliefs. In press. The Influence of Knowledge and Beliefs. In press. Journal of Journal of General Internal Medicine. (expected out online next week)General Internal Medicine. (expected out online next week)

Interview manuscript is in process…Interview manuscript is in process…

Contact information

Kathleen.mazor@umassmed.edu