Siekiant nustatyti vaistų vartojimo nurodymų nesilaikymo dažnumą ir su nesilaikymu siejamus veiksnius, namie apklausėme 36 pacientus, kuriems gydymo arba profilaktikos tikslais buvo skirti antimikrobiniai vaistai. Nustatyta, kad nurodymų netiksliai laikėsi 11 pacient�� (30,6 proc.), iš jų 6 (16,7 proc.) suvartojo mažiau vaistų nei nurodė gydytojas, 5 (13,8 proc.) daugiau nei nurodė gydytojas. Veiksniai, statistiškai patikimai siejami su vaistų vartojimo nurodymų nesilaikymu, buvo dažnas augalinių vaistų vartojimas, valgymas 2 kartus per dieną ar rečiau ir sprendimų, prieštaraujančių tiesioginiams vadovo ar sutuoktinio nurodymams, nepriėmimas. Pacientų nurodytos neteisingo vaistų vartojimo priežastys buvo užmir���imas (4/11, 36 proc.), noras pabaigti pakuotę (3/11, 27 proc.), neteisingai suprasti nurodymai (2/11, 18 proc.), nepakankamai įtikinama diagnozė, nenoras maišyti vaistus su alkoholiu, sveikatos pagerėjimas (po 1/11, 9 proc.). / In order to determine the rate of patient nonadherence and factors, related to nonadherence, we questioned 36 patients, who had been prescribed antimicrobial preparations. It was determined, that 11 patients (30,6%) did not adhere to their medications accurately, 6 of them (16.7%) used less doses than prescribed and 5 patients (13,8%) used more doses than prescribed. Factors, that were found to be statistically reliably related to nonadherence, were often use of herbal medicines, having 2 or less meals a day, tendency not to make decisions that would contradict direct guidelines, provided by their spouses or leadership. Reasons for nonadherence, as defined by patients, were forgetting to take a dose (4/11, 36%), intention to finish all doses in package (3/11, 27%), misunderstanding of guidelines, provided by doctor (2/11, 18%), unreliable diagnosis, fear of interaction with alcohol, improved health (1/11, 9% each).

ABSTRACT Many older African American adults have inadequate health literacy and are more likely to have chronic illnesses needing medication therapy. African Americans continue to experience significant health disparities in the incidences of cardiovascular disease and diabetes. It was postulated that ethnic disparities in medication compliance are related to a dynamic interplay between low health literacy and health locus of control. Thirty older African Americans taking at least one prescription medication were interviewed. Although the vast majority was well-educated, only 53% displayed adequate health literacy. Most of the participants believed they controlled their health, and over half were noncompliant with their medications. Poor health literacy and health locus of control appeared to influence medication compliance in older African Americans.

ABSTRACT Many older African American adults have inadequate health literacy and are more likely to have chronic illnesses needing medication therapy. African Americans continue to experience significant health disparities in the incidences of cardiovascular disease and diabetes. It was postulated that ethnic disparities in medication compliance are related to a dynamic interplay between low health literacy and health locus of control. Thirty older African Americans taking at least one prescription medication were interviewed. Although the vast majority was well-educated, only 53% displayed adequate health literacy. Most of the participants believed they controlled their health, and over half were noncompliant with their medications. Poor health literacy and health locus of control appeared to influence medication compliance in older African Americans.

Disruptive behavior problems are among the most commonly occurring forms of childhood psychopathology and show considerable stability beginning in early childhood. Investigations of the biological underpinnings of behavior problems have revealed that the influences of the parasympathetic branch of the autonomic nervous system on cardiac functions are central to self-regulation. Parasympathetic regulation of heart rate is indexed via respiratory sinus arrhythmia (RSA). Suppression of RSA during challenging emotional and cognitive tasks is associated with better emotional and behavioral functioning in preschoolers. However, the relationship between RSA suppression and preschool social functioning is still unclear. Further, direct relationships between behavior problems and RSA reactivity within command-based play tasks (i.e., child instructed to build 3 towers) with parents and other adults have yet to be examined. The present study experimentally evaluated the relationship between child RSA reactivity and adult (mother vs. staff) commands requiring child compliance during command-based play tasks in children ages 3-8 with and without disruptive behavior disorders (N=43). Child RSA suppression in response to commands was examined as a predictor of child command compliance during experimental play tasks and of general child behavior problems, and was compared across command-based interactions with mothers versus staff. Less RSA suppression in the context of mothers’ play-based commands was associated with more severe behavioral problems (p=.046). In the context of staff play-based commands, more RSA suppression was associated with more severe behavior problems (p=.009), an effect that was significant only among boys (p<.000). Further, greater child RSA suppression predicted greater compliance with mother-given commands (p=.017), but was unrelated to compliance with staff-given commands. The relationship between child RSA suppression and compliance with mother-given commands was moderated by child age, such that the effect of RSA suppression on child compliance was stronger for younger children than older children. Findings suggest that RSA reactivity to social demands, and the functional association between RSA suppression and behavioral compliance, vary by social context (i.e., mother vs. other adult command-givers) and identify child factors (i.e., age, gender) that influence these associations. This work may inform efforts to identify a biomarker of early childhood behavior problems.

As doenças crônicas estão entre as que mais crescem no Brasil e ao mesmo tempo apresentam alto índice de não adesão ao tratamento por parte dos pacientes. Apesar do esforço das políticas públicas, junto as campanhas de prevenção, conscientização e acesso aos medicamentos a essa população, a taxa de não adesão é alta. Pode-se dizer que os médicos e profissionais da saúde encontram algo que parece de difícil compreensão a partir do seu discurso: como pensar a ideia de que os pacientes parecem, de modo inusitado, se recusar a aderir ao tratamento? Segundo a Psicanálise, a questão da adesão não é simples: implica a maneira como cada paciente lida com o seu adoecimento. Dessa maneira, o presente trabalho, trata-se de um estudo teórico, com revisão bibliográfica e tem por objetivo propor uma ampliação teórica sobre a compreensão dada a não adesão em doenças crônicas. Nos valemos de conceitos centrais, tais como o inconsciente, a lógica entre demanda e desejo, o sintoma, passando por gozo e ato para compreender a não adesão como uma manifestação do sujeito do inconsciente. São objetivos específicos: a) levantar e percorrer a literatura científica produzida sobre a definição médica de doença crônica, índice de não adesão, fatores de risco para a não adesão e as formas de tratamento oferecidas para esses pacientes nas instituições de saúde. b) ampliar a discussão da não adesão ao tratamento da doença crônica, trazendo a ética da Psicanálise como pilar da atuação do analista nas instituições de saúde para poder propor propostas singulares aos pacientes que levem em conta a escuta do sujeito do inconsciente, c) discutir a importância da manutenção do analista na instituição e da transmissão dos efeitos analíticos como tática de inserir a Psicanálise na discussão das políticas públicas. A posição do analista nas instituições de saúde, se pauta pela impossibilidade de sustentar propostas universais em termos de tratamento que servem para todos. A não adesão a um tratamento significa muito mais do que simplesmente aderir ou não a uma prescrição médica. O avanço teórico e conceitual da não adesão, se faz necessário, pois aderir ao tratamento significa aderir uma nova condição de vida, é poder se apropriar de um corpo doente e não mais saudável como imaginado. Aderir é aceitar limitações e assumir uma queda da posição narcísica com o corpo. Portanto, o desafio que se coloca para o analista é poder propor e sustentar projetos terapêuticos singulares nas instituições á partir do estabelecimento de políticas públicas que levem em conta o sujeito do inconsciente. Uma práxis que não vai garantir a adesão, que não vai prescrever e nem convencer, mas que vai lidar com a dimensão do inconsciente, tão presente nas falas dos pacientes, sem se voltar para uma prática normativa, mas sim para uma escuta na direção do sintoma, da fantasia, do gozo e do ato, ou seja lidar com o sujeito / Chronic diseases are among the highest growing in Brazil and at the same time they present a high rate on noncompliance by the patients. In spite of the efforts of public policies, along with campaigns to raise prevention, awareness and access to medicine in that population, noncompliance rates are high. It can be said that doctors and health professionals encounter something that seems hard to comprehend from their discourse: how to think the idea that patients appear to, in usual fashion, refuse to adhere to treatment? According to Psychoanalysis, the question of adherence isnt simple: it implicates the way in which each patient deals with his illness. Thus, the present work is a theoretical study, with a bibliographical revision and has the objective of proposing a theoretical amplification on the comprehension of noncompliance in chronic diseases. Well use the main concepts, such as the unconscious, the logic between demand and desire, the symptom, as well as jouissance and act to understand noncompliance as a manifestation of the subject of the unconscious. The specific objectives are: a) to raise and travel the scientific literature regarding the medical definition of chronic disease, the rate of noncompliance, risk factors for noncompliance and the treatments offered for these patients at health institutions. b) to amplify the discussion of noncompliance to treatment of the chronic disease, bringing the ethics of Psychoanalysis as a pillar of the practice of the analyst in the health institutions in order to propose unique proposals to the patients that take into consideration the listening of the subject of the unconscious. c) to discuss the importance of the practice and position of the analyst in the institution and the transmission of the analytical effects as a tactic of inserting Psychoanalysis in the discussion of public policies. The position of the analyst in the health institutions is guided by the impossibility of sustaining universal proposals in terms of treatments that serve all. Noncompliance to a treatment means much more than simply adhering or not to a medical prescription. Theoretical and conceptual advances of noncompliance are necessary, for adhering to a treatment means adhering to a new life condition, it is being able to appropriate a body that is sick and no longer healthy as imagined. Adhering is accepting limitations and assuming a fall from the narcissistic position with the body. Therefore, the challenge that is presented for the analyst is to be able to propose and sustain singular therapeutic projects in institutions by the establishment of public policies that take into consideration the subject of the unconscious. A praxis that will not guarantee adhesion, that will not prescribe or convince, but one that will deal with the unconscious dimension, which are so present in the speech of patients, without turning to a normative practice, but to a listening in the direction of the symptom, the fantasy, of jouissance and the act, that is, dealing with the subject of the unconscious

Noncompliance to treatment allocation is likely to complicate estimation of causal effects in clinical trials. The ubiquitous nonrandom phenomenon of noncompliance renders per-protocol and as- treated analyses or even simple regression adjustments for noncompliance inadequate for causal inference. For survival data, several specialist methods have been developed when noncompliance is related to risk. The Causal Accelerated Life Model (CALM) allows time-dependent departures from randomized treatment in either arm and relates each observed event time to a potential event time that would have been observed if the control treatment had been given throughout the trial. Alternatively, the structural Proportional Hazards (C-Prophet) model accounts for all-or-nothing noncompliance in the treatment arm only while the CHARM estimator allows time-dependent departures from randomized treatment by considering survival outcome as a sequence of binary outcomes to provide an 'approximate' overall hazard ratio estimate which is adjusted for compliance. The problem of efficacy estimation is compounded for two-active treatment trials (additional noncompliance) where the ITT estimate provides a biased estimator for the true hazard ratio even under homogeneous treatment effects assumption. Using plausible arm-specific predictors of compliance, principal stratification methods can be applied to obtain principal effects for each stratum. The present work applies the above methods to data from the Esprit trials study which was conducted to ascertain whether or not unopposed oestrogen (hormone replacement therapy - HRT) reduced the risk of further cardiac events in postmenopausal women who survive a first myocardial infarction. We use statistically designed simulation studies to evaluate the performance of these methods in terms of bias and 95% confidence interval coverage. We also apply a principal stratification method to adjust for noncompliance in two treatment arms trial originally developed for binary data for survival analysis in terms of causal risk ratio. In a Bayesian framework, we apply the method to Esprit data to account for noncompliance in both treatment arms and estimate principal effects. We apply statistically designed simulation studies to evaluate the performance of the method in terms of bias in the causal effect estimates for each stratum. ITT analysis of the Esprit data showed the effects of taking HRT tablets was not statistically significantly different from placebo for both all cause mortality and myocardial reinfarction outcomes. Average compliance rate for HRT treatment was 43% and compliance rate decreased as the study progressed. CHARM and C-Prophet methods produced similar results but CALM performed best for Esprit: suggesting HRT would reduce risk of death by 50%. Simulation studies comparing the methods suggested that while both C-Prophet and CHARM methods performed equally well in terms of bias, the CALM method performed best in terms of both bias and 95% confidence interval coverage albeit with the largest RMSE. The principal stratification method failed for the Esprit study possibly due to the strong distribution assumption implicit in the method and lack of adequate compliance information in the data which produced large 95% credible intervals for the principal effect estimates. For moderate value of sensitivity parameter, principal stratification results suggested compliance with HRT tablets relative to placebo would reduce risk of mortality by 43% among the most compliant. Simulation studies on performance of this method showed narrower corresponding mean 95% credible intervals corresponding to the the causal risk ratio estimates for this subgroup compared to other strata. However, the results were sensitive to the unknown sensitivity parameter.

The Principal Stratification method estimates a causal intervention effect by taking account of subjects' differences in participation, adherence or compliance. The current Principal Stratification method has been mostly used in randomized intervention trials with randomization at a single (individual) level with subjects who were randomly assigned to either intervention or control condition. However, randomized intervention trials have been conducted at group level instead of individual level in many scientific fields. This is so called "two-level randomization", where randomization is conducted at a group (second) level, above an individual level but outcome is often observed at individual level within each group. The incorrect inferences may result from the causal modeling if one only considers the compliance from individual level, but ignores it or be determine it from group level for a two-level randomized trial. The Principal Stratification method thus needs to be further developed to address this issue. To extend application of the Principal Stratification method, this research developed a new methodology for causal inferences in two-level intervention trials which principal stratification can be formed by both group level and individual level compliance. Built on the original Principal Stratification method, the new method incorporates a range of alternative methods to assess causal effects on a population when data on exposure at the group level are incomplete or limited, and are data at individual level. We use the Gatekeeper Training Trial, as a motivating example as well as for illustration. This study is focused on how to examine the intervention causal effect for schools that varied by level of adoption of the intervention program (Early-adopter vs. Later-adopter). In our case, the traditional Exclusion Restriction Assumption for Principal Stratification method is no longer hold. The results show that the intervention had a stronger impact on Later-Adopter group than Early-Adopter group for all participated schools. These impacts were larger for later trained schools than earlier trained schools. The study also shows that the intervention has a different impact on middle and high schools.

No description available.

No description available.

An experiment was conducted to evaluate the effect of the Precision Request as a behavior intervention on the compliance behavior of students in a self-contained class for students with emotional-behavioral disorders. The Precision Request is an intervention commonly used by teachers to decrease noncompliance. The study took place in an elementary school behavior unit classroom. The participants included one special education teacher and the eight students in his class. A single subject reversal design was used to track student percentage of compliance, latency to compliance, as well as teacher use of praise and reductive consequences as part of the Precision Request intervention. The results indicated that the Precision Request produced a decrease in noncompliance among the students. However, it did not produce a meaningful change in latency to compliance. The introduction of the Precision Request also resulted in an increase in the teacher's use of praise, but no meaningful change in the use of reductive consequences. More research is needed to establish the active components of the intervention and the generality of the intervention effects.