Times’ medicine: temporal discounting and future-self continuity

How we perceive the implications of an illness and potential treatments in the present compared to the future can shape our attitudes towards treatments and thus influence adherence and outcomes.

We have a tendency to choose small short-term gains over long-term larger ones, which is described as temporal discounting. The value of an item today appears to be worth more than in the future.

This tendency to make choices which bias the present, often to our long-term detriment, is particularly prominent in smokers1 and can also be applied to medical adherence. Discounting in the value of future health risks, has been found to be correlated with adherence and treatment outcomes in both diabetes2,3 and multiple sclerosis.4,5

One potential reason why we favour the present could be linked to future-self continuity, how we perceive ourselves now, in comparison to ourselves in the future. This also links to illness perception. If the person does not feel ill, the benefit is not obvious, so it is difficult for patients to even discount.

In experiments, when participants are asked to assess how similar they perceived themselves to their future self, using the sets of circles (see below) and then undertake a temporal discounting task to see how likely they were to choose delayed monetary rewards (e.g. £15 today or £50 in three months), future-self similarity (assessed by the circle task) correlate with their likelihood of choosing delayed reward. The more similar people perceive themselves as more similar to their future self the more they save.7

When shown avatars of either in their current state or looking elderly as a retired version of themselves8 and asked questions such as: How much of your current income would you like to allocate for your retirement fund? Seeing the older avatar of themselves people increase the average percentage of their income they would choose to save.8

This has strong implications as it demonstrates that making a connection with our future self can help us make better, more forward-thinking plans, and patients make treatment choices more aligned with their long-term needs.

1. Bickel W, Odum A, Madden G. Impulsivity and cigarette smoking: Delay discounting in current, never, and ex-smokers. Psychopharmacology. 1999;146 (4): 447-454.

2. Lansing A, Stanger C, Crochiere R, et al. Delay Discounting and Parental Monitoring in Adolescents with Poorly Controlled Type 1 Diabetes. Journal of Behavioral Medicine. 2017

3. Lebeau G, Consoli M, Le Bouc R, et al. Delay Discounting of Gains and Losses, Glycemic Control and Therapeutic Adherence in Type 2 Diabetes. Behavioural Processes. 016;132: 42–48.

4. Bruce J, Bruce A, Catley D, et al. Being Kind to Your Future Self: Probability Discounting of Health Decision-Making. Annals of Behavioral Medicine: A Publication of the Society of Behavioral Medicine. 2016;50 (2): 297–309.

5. Jarmolowicz D, Reed D, Bruce A, et al. Using EP50 to Forecast Treatment Adherence in Individuals with Multiple Sclerosis. Behavioural Processes. 2016;132: 94–99.

6. Hershfield H, Wimmer G, Knutson B. Saving for the future self: Neural measures of future self-continuity predict temporal discounting. Soc Cogn Affect Neurosci. 2009;4 (1): 85-92.

7. Hershfield H, Garton M, Ballard K, et al. Don’t stop thinking about tomorrow: Individual differences in future self-continuity account for saving. Judgment and Decision Making. 2009;4(4): 280–286

8. Hershfield H, Goldstein D, Sharpe F, et al. Increasing Saving Behavior Through Age-Progressed Renderings of the Future Self. Journal of Marketing Research. 2011;48: S23–S37

Informed Consent – How much is too much?

Can too much information be harmful to your health? Informed consent is at the heart of many ongoing debates that seek to answer this question.

Informed consent refers to the permission granted in full knowledge of the possible consequences. Typically, it relates to that which is given by a patient to a doctor for treatment with knowledge of the possible risks and benefits. However, informed consent is a process that occurs both within healthcare and any research involving human studies.

There are many limitations and issues surrounding the process of informed consent that bring in to question its validity. One area that we at Spoonful of Sugar regularly consider within our work is the information that is given to patients around treatment side effects.

The informed consent process has the potential to increase patients experience of side effects purely by the mentioning of them as providing extensive information regarding adverse effects can generate nocebo responses; when the expectation of treatment side effects leads to those symptoms being realised. Extensive research has shown that including specific side effects within a consent form increases the incidence of the reporting of these symptoms. The variability in an individual’s risk perception in relation to side effects adds complexity to the issue.

Over the years researchers have investigated methods for minimising these nocebo responses whilst still maintaining patient autonomy, these are approaches SoS considers when designing patient support. One approach that has been suggested is contextualised consent which proposes a tailored approach to the information given, it considers adverse effects of a particular medication, the patient themselves and the illness concerned. Another method looks at how the information is presented, studies have shown that positive framing and personalising information helped patients to develop more functional treatment expectations and prevented expectation induced nocebo effects. These two techniques; framing and tailoring could go a long way to providing an effective informed consent procedure.

As of yet no consensus has been reached on the best way to approach the complex topic of informed consent and so continues the debate of ‘how much information really is too much?’

 

Lost in Translation – understanding cultural and linguistic differences for successful adherence programmes

We love the movie ‘Lost in Translation’ with Bill Murray, it really captures how things can go wrong and easily be misunderstood with differences in culture and language.

Running adherence programmes internationally requires a deep understanding of the role of culture and language. Cultural and language differences have a direct impact on how successful an adherence program will be. It is hard to be aware of every single aspect of each country’s culture from afar. That’s why we really do take this factor into account and have an international team in place to create effective programs efficiently.

It is good to remind ourselves that in life, communication is key to success. Being aware of cultural backgrounds is key to the adoption and use of programmes. Direct translation rarely effectively translates all intended meaning. This is also why we conduct research, because customer needs and demands, decision making, and social role views all varies by culture, and to understand the exact words and meaning ascribed to those words in the language and context the program will be
delivered.

We have yet to find a better way than using people who are native speakers of the language, have been immersed in the culture and are trained in the underpinning psychological constructs.

 

Importance of the person-centred approach

As the world becomes increasingly entrenched in big data, one must stop and ask – what will happen to our individuality? This 2-minute whiteboard video will discuss these issues and highlight the importance of the person-centred approach.

Adherence: transforming cure into care

Within the field of medical adherence, we become equipped with the phrases to explain the importance of what we do. We learn the chorus: approximately 50% of patients do not take medicines they are meant to; communication barriers between clinicians and patients can leave adherence unaddressed; poor adherence leads to increased morbidity and mortality. Swimming in p values and questionnaires and segmentation, it is sometimes easy to forget the worth of empowering patients by investigating non-adherence to our patients.

The need for patient empowerment is echoed throughout healthcare and we know that involving patients in conversations about adherence is part of this. Many of the constructs that define patient empowerment, such as personal control and self-efficacy, are synonymous with the theories behind Spoonful of Sugar (SoS) frameworks that measure and understand adherence. If knowledge is power, then our frameworks enable us shape adherence programmes in a way that responds to and gives weight to our patients’ needs and values. But what worth does this hold for patients?

By listening to what patients think about their medication regime, we add value to how patients feel, and appreciate how complicated this can be. As someone whose medical files are laced with finger-tip-unit-only steroids, count-to-five-between-puffs inhalers, and “I nag because I care” relatives, it is comforting to know that adherence studies humanise us. Our researchers remove the fear of stigmatising labels such as “lazy”, “ignorant” and “ungrateful” by understanding the complexity of behaviour. Our approach breaks down the “them” and “us” wall between healthcare professionals and patients. We encourage empathetic care and create opportunities to share repressed worries and frustrations. Our knowledge of adherence does empower patients, but ultimately, we ensure cure is transformed into care.

There is no p value to measure the relief we feel when we can voice our thoughts on our treatment, but the significance of being understood cannot be over stated.

Empowering patients: Better Health Outcomes through Adherence

In a previous blog we introduced the concept of the 4-state Necessity beliefs and Concerns Framework (NCF)™ map as a way of “visualising” patients’ likelihood to adhere to their treatment. Using the same NCF, this time we are focusing on patient’s treatment-related empowerment as a driver for adherence, i.e., does a patient being empowered affect their motivation to adhere to medication to manage their long-term conditions, as shown through their location in the NCF.

Recently, Patient Centricity has become a mantra in Health – from policy makers to industry and patient’s associations to healthcare stakeholders, all claim that empowering patients to take more control on their treatment leads to better health outcomes. Makes sense, now let’s show one way empowerment creates a direct route to improved health outcomes through better adherence.

Our recent studies based on patient’s self-reported empowerment, using the Treatment-related Empowerment Scale (TES)™ and their Necessity beliefs and Concerns,were measured using the Beliefs about Medication Questionnaire (BMQ)™. This showed there is an important correlation between these concepts; superior empowerment of patients with long-term conditions helps them have an Accepting attitude towards their medications.

Interestingly this approach can be a building block to provide a valuable estimate of how much increasing empowerment increases adherence. By way of example, the below table provides an estimated average adherence to treatment for patients with Type 2 Diabetes Mellitus according to their “location” on the 4-state NCF map following assessment of their perceptions of their medication.

Using the above data and large dataset correlating TES™ and BMQ™, we can infer an almost 9% to 10% increase in adherence to treatment in the more highly empowered patients compared to those poorly empowered.

Want to know more? Give us a call. We’ll be delighted to help you.

1 Mann, D., Ponieman, D., Leventhal, H., & Halm, E. (2009). Predictors of adherence to diabetes medications: the role of disease and medication beliefs. Journal of Behavioral Medicine, 32(3), 278-284.

How predictable could patient’s adherence to treatment be?

Patients taking medications to manage their long-term conditions show different attitudes over time. We have demonstrated time and again that patient’s motivations to adhere to their treatment obey to their necessity beliefs and concerns regarding their medication and those beliefs drive their behaviours. The fact that these behavioural drivers exist means that behavioural changes following an intervention on a cohort leads to changes on the overall adherence. Obvious!… but is it predictable?

 

 

The Necessity beliefs and Concerns Framework (NCF™) has a two-dimensional spatial representation for mapping patient’s location into 4 quadrants each one representing one of 4-states [Sceptical (low Necessity beliefs, high Concerns), Ambivalent (high, high), Indifferent (low, low), Accepting (high, low)] based on their answers to the Beliefs about Medication Questionnaire (BMQ™). This is certainly not a static situation over time and it is at the core of SoS behavioural change methodology to create informed patients, so their choice guide their “movements” across the 4-states NCF™ map. Why? Because patients’ adherence to their treatment is strongly dependant on their psychological state… and there is obviously an ideal state [Accepting] where their necessity beliefs are high and have low concerns about their medication which leads to superior adherence levels, which improves their health. This does not mean that patients in the other 3 states are not adherent at all, but it is so much simpler to achieve the highest levels of adherence no matter the disease area when patients are in this Accepting state (for instance, 6 times more for patients with type 2 diabetes mellitus) that it worth all necessary efforts and costs from healthcare stakeholders.

 

Remember: no patient’s location in the 4-state NCF™ map is eternal, so the good thing is that we can design interventions to change patient’s behaviour to help them become more adherent, and the bad thing is that there are counteracting external forces that negatively impact on their motivations to “move”. Patients conscious and unconscious choices lead to “movement” across the 4-state NCF™ map. Understanding patients’ intrinsic and extrinsic motivations through the Perceptions and Practicalities Approach (PAPA™) is key to laying the pathway for change and proceeding with bespoke patients’ behavioural change programme is an integral part of any Patient Support Programme.

 

For those of you who think “the shortest distance between 2 points is the straight line” … Yep! This is not always evident, at least in the 4-state NCF™ map for those Sceptical patients who face a dilemma: can they both reverse their low Necessity beliefs and high Concerns at the same time? Possible but difficult. Transitions tend to occur sequentially so it is likely patients “move” from a Sceptical state to an intermediate state [Ambivalent, Indifferent] through behavioural change programmes rather than “jumping” directly towards the Accepting state.

 

And here is your food for thought: Which is the optimum pathway to acceptance, is it more difficult to first raise a patients’ low Necessity beliefs or lowering their high Concerns. And a related thought: Should you aim to first “move” those patients in an Indifferent state towards the Accepting state by heighten their Necessity beliefs or transforming Ambivalent patients into Accepting patients by lowering their Concerns. If these questions are bothering you, as you look to create optimally effective Patient Support Programme, then we look forward to hearing from you.

PAPA™: Don’t Preach

The Perceptions and Practicalities Approach (PAPA™) works by conceptualising nonadherence as a complex behaviour. A complex behaviour can have multiple causes, in the same patient, at any one time. Those causes can be intentional, when the patient actively chooses not to adhere as a response to their beliefs or perceptions. Or the causes can be unintentional, when the patient faces some practical barrier to optimum adherence.

 

We design our programmes according to our proprietary framework (PAPA™), which outlines the key features most likely to ensure the programme’s efficacy. These essential features address the perceptions underlying medicines behaviour, i.e. their motivation to adhere. These key features also address the practicalities facilitating or hindering optimal adherence, i.e. the patient’s ability to adhere.

 

We tailor the support needed to the needs of the individual. When patients feel that their perspective has been taken into account, they are more likely to engage with an adherence support programme, because they don’t feel preached to or, even worse, preached at.

 

Programme design is more precarious than it seems. If you address the wrong perceptions (how patients perceive the risks of their illness rather than of their treatment), you will generally fail, because perception alone cannot mediate adherence behaviour. If you assess perceptions without addressing them, you will generally fail as your efforts at meaningful communication with the patient will fall short of directly dismantling the barrier.

 

If you do not refine your strategy to target the salient barriers to be overcome, for example by using practical solutions to resolve perceptual barriers (or vice versa), you will generally fail because communication will ring hollow. For best effects, we use PAPA™ in tandem with our other approaches and frameworks to design an effective, constantly-evolving adherence support programme, co-created with patients, that makes the most of your medicine.

 

So when you want to transform adherence? PAPA™, don’t preach.