Optimising recovery and adherence to treatment in patients with major physical health problems
Submitting InstitutionKing's College London
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Clinical Sciences, Public Health and Health Services
Psychology and Cognitive Sciences: Psychology
Summary of the impact
Poor treatment adherence and self-management are universally recognised
as major problems across all illnesses. Research at Kings College London
(KCL) has resulted in new ways of assessing, investigating and improving
these problems. These are now achieving widespread impact through the
highly successful commercial organisation Atlantic Healthcare, which
provides medication adherence and patient support programmes on a global
scale. These programmes, which are now reaching patients with over 50
major medical conditions in a large number of countries, are very solidly
based on the findings from KCL research.
There is growing evidence that variability in the psychosocial effects of
major physical illness, and recovery from such, is in part due to
patient's perception of, and behavioural and/or emotional responses to,
their illness. Prof John Weinman (1990-present, Professor of Psychology as
Applied to Medicines) and colleagues at King's College London (KCL) have
developed and validated methods for assessing patients' perceptions of
illness and treatment. Much of this research has been in collaboration
with Prof Keith Petrie at Auckland Medical School, New Zealand.
Adjustment to Illness
In the mid 1990's, KCL researchers developed the psychometrically robust
Illness Perception Questionnaire (IPQ), one of the first to provide valid
and reliable measures of the ways in which patients make sense of their
illness. Development involved initial qualitative studies to elicit key
statements from patients, followed by a series of studies and statistical
analyses to establish the reliability and validity of the scales. The five
scales of the IPQ assess identity (symptoms the patient associates with
the illness); cause (personal ideas about aetiology); time-line (perceived
illness duration); consequences (expected effects and outcome) and cure
control (how one controls/recovers from the illness). The IPQ has a number
of core items and allows the user to add items for particular patient
groups or health threats (1).
This questionnaire has been used in many KCL studies that have shown the
significant contribution that patient's perception of their illness can
make to their recovery from and/or adaptation to a major health problem.
For example, in a study to measure causal beliefs in 141 individuals with
psoriasis, 61% had a strong belief in stress and/or psychological
attributes as causal factors, a belief significantly associated with
higher levels of anxiety, depression and perceived stress (2).
Other studies have provided extensive evidence of the role of illness
perceptions in predicting behaviour change, illness adjustment and quality
of life. For instance, in a study involving 125 patients with rheumatoid
arthritis, higher disability scores were significantly associated with
beliefs about identity and consequences. Stronger control beliefs were
associated with lower disability and better physical quality of life (3).
KCL researchers have also looked at patient's beliefs in mental illness.
Using the IPQ with 92 patients with a recent relapse of psychosis, it was
found that those who failed to attend cognitive behaviour therapy sessions
believed their problems would not last as long as those who did attend.
Those who attended sessions but didn't proceed to full therapy had a lower
sense of control over their problems and a more biological view of their
causes. Patients who took up full therapy were more likely to attribute
the cause of their problems to their personality and state of mind (4).
Adherence to treatment
KCL researchers have also developed psychometrically sound measures for
assessing patients' beliefs about their medication. The two section
Beliefs about Medicines Questionnaire (BMQ) is composed of the
BMQ-Specific, with two 5-item factors assessing beliefs about the
necessity of prescribed medication and concerns about prescribed
medication, and the BMQ-General, with two 4-item factors assessing beliefs
that medicines are harmful, addictive, poisons which should not be taken
continuously and that medicines are overused by doctors. The two sections
of the BMQ can be used in combination or separately (5). Researchers at
KCL have carried out a number of studies with a BMQ adapted for assessing
patients' beliefs about cardiac rehabilitation. An initial study of 152
cardiac patients, of whom 41% had attended such sessions, showed
non-attenders were less likely to believe their condition was controllable
and that their lifestyle may have contributed to their illness (6). The
development of a 26-item `Beliefs about Cardiac Rehabilitation'
questionnaire was carried out with 130 patients with acute myocardial
infarction. Four subscales pertaining to patients' beliefs about cardiac
rehabilitation were produced. Patients who attended rehabilitation were
significantly more likely to believe it was necessary and to understand
its role compared with non-attenders. Patients who thought cardiac
rehabilitation was suitable for a younger, more active person were
significantly less likely to attend (7).
Further studies have used both the IPQ and the BMQ to evaluate adherence
to preventer medication for asthma. Findings showed that non-adherent
behaviours were associated with doubts about the necessity of medication
and concerns about its potential adverse effects and with more negative
perceived consequences of illness. Illness perceptions influenced
adherence both directly and indirectly via treatment beliefs, which, in
turn, were the strongest predictors (8).
References to the research
1. Weinman J, Petrie K, Moss Morris R, Horne R. The Illness Perception
Questionnaire: A new method for assessing the cognitive representation of
illness. Psychology Health 1996;11:431-45. Doi: 10.1080/08870449608400270
(610 Scopus citations).
2. O'Leary CJ, Creamer D, Higgins E, Weinman J. Perceived stress, stress
attributions and psychological distress in psoriasis. J Psychosom Res
2004;57(5):465-71. Doi: 10.1016/j.jpsychores.2004.03.012 (38 Scopus
3. Graves H, Scott DL, Lempp H, Weinman J. Illness beliefs predict
disability in rheumatoid arthritis. J Psychosom Res 2009;67(5):417-23.
Doi: 10.1016/j.jpsychores.2009.01.006 (15 Scopus citations)
4. Freeman D, Dunn G, Garety P, Weinman J, Kuipers E, Fowler D, Jolley S,
Bebbington P. Patients' beliefs about the causes, persistence and control
of psychotic experiences predict take-up of effective cognitive behaviour
therapy for psychosis. Psychol Med 2013;43(2):269-77. Doi:
10.1017/S0033291712001225 (0 Scopus citations: recent publication)
5. Horne R, Weinman J, Hankins, M. The beliefs about medicines
questionnaire: the development and evaluation of a new method for
assessing the cognitive representation of medication. Psychology Health
1999;14(1)1-24. Doi: 10.1080/08870449908407311 (434 Scopus citations)
6. Cooper A, Lloyd G, Weinman J, Jackson G. Why patients do not attend
cardiac rehabilitation: role of intentions and illness beliefs. Heart
http://heart.bmj.com/content/82/2/234.long(142 Scopus citations)
7. Cooper AF, Weinman J, Hankins M, Jackson G, Horne R. Assessing
patients' beliefs about cardiac rehabilitation as a basis for predicting
attendance after acute myocardial infarction. Heart 2007;93(1):53-8. Doi:
10.1136/hrt.2005.081299 (30 Scopus citations)
8. Horne RA, Weinman JB. Self-regulation and self-management in asthma:
Exploring the role of illness perceptions and treatment beliefs in
explaining non-adherence to preventer medication. Psychol Health
2002;17(1):17-32. Doi: 10.1080/08870440290001502 (242 Scopus citations)
Grants PI/Co PI: John Weinman
• 1998-2000. The role of patients beliefs about illness and treatment in
adherence medication for heart failure. South Thames NHS Research &
• 2000-2001. Pilot study of patients' illness and treatment beliefs and
their relation to treatment compliance in asthma. National NHS R & D
and National Asthma Campaign, £26,548
• 2002-2004. Study of patients' illness and treatment beliefs and their
relation to treatment compliance in asthma. National NHS R & D and
National Asthma Campaign, £188,631
Details of the impact
The two specific areas of underpinning research by King's College London
(KCL) outlined above have enabled clinicians and researchers to gain a
greater understanding of patients' illness and treatment perceptions and
their effects on a wide range of illness-related behaviours and health
outcomes. This, in turn, has resulted in the development of psychological
interventions, which have been found to be effective not only in modifying
dysfunctional illness beliefs and improving recovery, quality of life and
mood, but also in improving treatment adherence by changing negative
illness and treatment beliefs.
The success of the work described above has been recognised by Atlantis
Healthcare, a leading worldwide commercial provider of patient adherence
and support programmes with offices in Europe, Australasia and the United
States (1). Atlantis Healthcare works closely with a number of leading
pharmaceutical companies and with public health organisations to provide
effective interventions for patients to manage their illness and
treatment. They employ a large team of health psychologists worldwide and
involve Prof Weinman in a consultancy role and as Head of the European
Health Psychology team (2, 3). Much of Atlantis Healthcare's approach is
based on the underpinning research and the assessments and interventions
described above. Their interventions are tailored to elicit and, if
necessary, modify patients' illness and treatment beliefs, both of which
are routinely assessed using the measures developed at KCL.
Atlantis Healthcare has delivered over 80 programmes across 51 disease
states including: Alzheimer's disease, asthma, breast cancer, diabetes,
erectile dysfunction, glaucoma, gout, growth hormone deficiency,
haemophilia, hearing loss, hepatitis C, incontinence, lung cancer,
osteoporosis, pain, rheumatoid arthritis and wet AMD, among others, as
well as programmes to support health screenings and blood donor
management. The evidence base on their website lists a large number of
published studies by KCL and collaborators (including Weinman 1996, Cooper
1999, Horne 1999, and Freeman 2012), which have shown not only that
patients' illness beliefs, as measured by the IPQ, consistently predict an
important range of clinical and psychosocial outcomes of illness but also
that interventions based on these findings have successfully improved many
of these outcomes (3).
In a letter of professional support, the Managing Director of Atlantic
Healthcare UK, says that:
"as an acknowledged global market leader in the provision of patient
adherence support programmes, our distinctiveness and acclaimed success
is highly dependent on the fact that our approach is very much based on
the rigorous and proven approaches, which have been pioneered by
Professor Weinman and his colleagues at Kings College London over the
past 15 years."
He discusses how they are currently running 12 programmes for patients
with a wide range of long term health problems, saying that:
"the core clinical basis of these programmes and communications
approach are based on Prof Weinman's highly influential research on
assessing and modifying patients' beliefs about illness and treatment."
Atlantis Healthcare's Managing Director also details how their `One
Heart' programme, funded by Astra Zeneca and running in three countries,
is based on:
"the findings from (KCL) research on evaluating and improving illness
beliefs in patients following myocardial infarction."
Here he cites Cooper 1999 and 2007 along with a number of collaborative
studies with Auckland Medical School (4).
In Addition, the Managing Director says that KCL's:
"research on the role of illness perception in the outcome of major
inflammatory diseases, such as rheumatoid arthritis (citing Graves
2009) and psoriasis (citing O'Leary 2004), has enabled us to
develop global patient adherence support programmes in collaboration
with AbbVie and Leo Laboratories, which are being offered to patients in
many countries around the world" (4).
Atlantis Healthcare's Rheumatology Care Patient Workbook for AbbVie,
which included KCL work, won a 2013 Communique Award for Writing
Excellence with judges commenting that "We selected this as a winner
because it successfully combined the behavioural factors, which
underpinned the programme, with clear and engaging writing that would be
very appealing to patients with rheumatoid arthritis. It is genuinely
savvy, making very good use of psychology and behaviour change theory"
Similarly, in another letter of support the CEO of Atlantis Healthcare
"we quickly recognised that the research by Professor Weinman and his
colleagues at King's College London could provide the basis for the
development of our own global programmes."
She cites Weinman 1996 and Horne 1999 as being particularly influential
and goes on to say that: "of particular value for our programmes is
that Professor Weinman's approaches allow us to assess each patient's
beliefs and motivation in an individualised way, and then to offer
tailored interventions based on this understanding."
The CEO of Atlantis Healthcare also corroborated that:
"the really impressive results obtained by Professor Weinman and
colleagues in developing successful interventions for patients across a
wide range of serious health problems, including end stage renal disease
and cardiac disease (citing Cooper 2007) have provided us with
the evidence base and the confidence to build our own programmes, which
we now offer to close to a million patients in 15 countries. In this
way, his research is achieving considerable impact in the lives of many
patients around the world" (6).
Illness Perception Questionnaire Website
The questionnaires developed by KCL and colleagues have been translated
into over 20 languages and modified for a number of different diseases.
For instance, the Illness Perception Questionnaire (IPQ) has been
translated into French, Italian, Norwegian, Romanian, Samoan, Tongan and
Sri Lankan and adapted for specific use in those with diabetes, chronic
fatigue syndrome, hypertension and HIV. Working with colleagues at the
Auckland Medical School, New Zealand, there is now a revised IPQ (IPQ-R)
and a brief version. All these versions are available on an open access
website, which has attracted over 100,000 hits from researchers from all
around the world. The website includes the key papers, describing the
development and application of the different versions of the IPQ,
including Weinman 1996 (7).
Findings from KCL studies have provided the basis for effective new
interventions for patients and carers. For example, following from Horne
and Weinman's 2002 study identifying the key beliefs underlying patients'
levels of adherence to preventer medication in patients with asthma, an
innovative text messaging intervention was developed with colleagues at
the Auckland Medical School to change patients' illness and treatment
beliefs. The intervention has been evaluated in a recently published
randomised controlled trial involving 216 patients aged between 16 and 45.
Two texts were sent daily for 6 weeks, one text daily for another 6 weeks,
then three texts per week for a further 6 weeks. The type of texts sent
was determined by the participant's baseline scores on a modified version
of the IPQ and the level of medication belief ratings. Results showed that
text messaging was not only successful in bringing about changes in
patients' beliefs but that this resulted in a significant uplift in
reported treatment adherence, maintained 6 months after the intervention
had stopped (8).
Sources to corroborate the impact
- Atlantis Healthcare: www.atlantishealthcare.com/
- Professor John Weinman: http://www.atlantishealthcare.com/Clinical-Team/
- Evidence base: http://www.atlantishealthcare.com/about-us/our-evidence-base
- Letter of professional support from the Managing Director for Atlantic
- Lions Den Award for Writing Excellence - Patients. Awarded July 4th
- Letter of professional support from the Global CEO of Atlantic
- Illness Perception Questionnaire: www.uib.no/ipq/
- Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme
designed to modify patients' illness and treatment beliefs improves
self-reported adherence to asthma preventer medication. Br J Health
Psychol 2012;17(1):74-84. Doi: 10.1111/j.2044-8287.2011.02033.x