Wu Yan Fei. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2003. / Includes bibliographical references (leaves 161-189). / Abstracts in English and Chinese. / Chapter 1. --- BACKGROUND --- p.1 / Chapter 1.1 --- Hong Kong health care system --- p.1 / Chapter 1.2 --- Medication compliance and treatment responses --- p.2 / Chapter 1.3 --- Definition of compliance --- p.5 / Chapter 1.3.1 --- Compliance --- p.5 / Chapter 1.3.2 --- Adherence --- p.6 / Chapter 1.3.3 --- Concordance --- p.7 / Chapter 1.4 --- Definitions of satisfactory compliance --- p.9 / Chapter 1.5 --- Importance of compliance --- p.10 / Chapter 1.6 --- Non-compliance as a behavioral disease --- p.12 / Chapter 1.6.1 --- Disease manifestation (Patterns of non-compliance) --- p.12 / Chapter 1.6.2 --- Prevalence/Epidemiology (Rate of non-compliance) --- p.14 / Chapter 1.6.3 --- Diagnosis (Detecting non-compliance) --- p.15 / Chapter 1.6.3.1 --- Direct methods --- p.16 / Chapter 1.6.3.1.1 --- Use of biological fluids --- p.17 / Chapter 1.6.3.1.2 --- Biological surrogate (Drug) markers --- p.18 / Chapter 1.6.3.1.3 --- Pharmacological indicators --- p.20 / Chapter 1.6.3.2 --- Indirect methods --- p.22 / Chapter 1.6.3.2.1 --- Self-report / Direct questioning --- p.24 / Chapter 1.6.3.2.2 --- Pill counts --- p.25 / Chapter 1.6.3.2.3 --- Diaries --- p.27 / Chapter 1.6.3.2.4 --- Electronic monitoring --- p.27 / Chapter 1.6.3.2.5 --- Physician estimates --- p.31 / Chapter 1.6.3.2.6 --- Outcome measurement and clinical judgment --- p.32 / Chapter 1.6.3.2.7 --- Presence of side effects --- p.33 / Chapter 1.6.3.2.8 --- Keeping of appointments --- p.34 / Chapter 1.6.3.2.9 --- Prescription refill rates --- p.34 / Chapter 1.6.3.3 --- Direct observation --- p.35 / Chapter 1.6.3.4 --- The ideal detection method --- p.36 / Chapter 1.6.4 --- Risk factors (Related factors of non-compliance) --- p.37 / Chapter 1 .6.4.1 --- Patient related factors --- p.37 / Chapter 1.6.4.1.1 --- Understanding and comprehension --- p.37 / Chapter 1.6.4.1.2 --- Health beliefs --- p.39 / Chapter 1.6.4.1.3 --- Socio-demographic factors --- p.44 / Chapter 1.6.4.1.4 --- Forgetfulness --- p.45 / Chapter 1.6.4.2 --- Illness --- p.46 / Chapter 1.6.4.3 --- Therapeutic regimen --- p.46 / Chapter 1 .6.4.4 --- Patient-practitioner relationship --- p.48 / Chapter 1.6.5 --- Treatment (Interventions) --- p.50 / Chapter 1.6.5.1 --- Education --- p.51 / Chapter 1.6.5.2 --- Dosing regimen planning --- p.55 / Chapter 1.6.5.3 --- Clinic scheduling --- p.57 / Chapter 1.6.5.4 --- Communication --- p.57 / Chapter 1.6.6 --- Intelligent non-compliance --- p.60 / Chapter 1.6.7 --- Overview of problems with compliance studies --- p.63 / Chapter 1.6.7.1 --- Complex and not effective --- p.64 / Chapter 1.6.7.2 --- Lack theoretical framework --- p.64 / Chapter 1.6.7.3 --- Fragmented studies --- p.65 / Chapter 1.6.7.4 --- Lack high quality compliance study --- p.66 / Chapter 1.6.7.5 --- Without long term follow up --- p.67 / Chapter 1.6.7.6 --- Correlation between compliance and desired therapeutic outcomes --- p.68 / Chapter 2 --- HYPOTHESIS AND OBJECTIVES --- p.71 / Chapter 3 --- METHODS --- p.75 / Chapter 3.1 --- Study design --- p.76 / Chapter 3.2 --- Outcome measures --- p.80 / Chapter 3.3 --- Statistical analysis --- p.81 / Chapter 3.4 --- Power analysis --- p.82 / Chapter 4. --- RESULTS --- p.85 / Chapter 4.1 --- Patient demographics --- p.85 / Chapter 4.2 --- Clinic attended and drug usage --- p.85 / Chapter 4.3 --- Non-compliant rates and its patterns --- p.86 / Chapter 4.4 --- Reasons for non-compliance --- p.86 / Chapter 4.5 --- Relationship between drug class and medication compliance --- p.86 / Chapter 4.6 --- Relationship between dosage frequency and medication compliance --- p.87 / Chapter 4.7 --- Clinical characteristics of compliant and non-compliant patients --- p.87 / Chapter 4.8 --- Comparison of non-compliant patients identified at baseline during the second reassessment --- p.88 / Chapter 4.9 --- Effects of pharmacist's telephone intervention on tertiary outcomes --- p.88 / Chapter 4.9.1 --- Medication compliance --- p.88 / Chapter 4.9.2 --- Blood pressure --- p.89 / Chapter 4.10 --- Effects of pharmacist's telephone intervention on secondary outcomes --- p.90 / Chapter 4.11 --- Primary end-points of compliant versus non-compliant patients --- p.91 / Chapter 4.12 --- Best predictors of mortality rate for the studied population --- p.92 / Chapter 4.13 --- Effects of pharmacist's telephone intervention on primary outcomes --- p.92 / Chapter 4.14 --- Clinical characteristics of non-compliant patients with / without second follow up --- p.93 / Chapter 4.15 --- Clinical outcomes of defaulted patients at the second visit --- p.93 / Chapter 5. --- DISCUSSION --- p.126 / Chapter 5.1 --- Study design --- p.126 / Chapter 5.2 --- Compliance assessment method --- p.126 / Chapter 5.3 --- Patient demographics and drug prescribing pattern --- p.128 / Chapter 5.4 --- Extent and pattern of non-compliance --- p.128 / Chapter 5.5 --- Reasons for non-compliance --- p.129 / Chapter 5.5.1 --- Lack of knowledge --- p.129 / Chapter 5.5.1.1 --- Dosing instructions --- p.129 / Chapter 5.5.1.2 --- Drug identification --- p.130 / Chapter 5.5.1.3 --- Storage --- p.131 / Chapter 5.5.2 --- Forgetfulness --- p.131 / Chapter 5.5.3 --- Problems with health beliefs --- p.132 / Chapter 5.5.3.1 --- Common myths or misconceptions --- p.132 / Chapter 5.5.4 --- Presence of side effects --- p.133 / Chapter 5.6 --- Predictability of non-compliance --- p.134 / Chapter 5.6.1 --- Socio-demographics --- p.134 / Chapter 5.6.2 --- Polypharmacy --- p.135 / Chapter 5.6.3 --- Dosing frequency --- p.137 / Chapter 5.6.3.1 --- "Little difference between daily, twice daily and thrice daily dosing." --- p.137 / Chapter 5.6.3.2 --- Importance of drug property in determining the impact of usual dosages --- p.138 / Chapter 5.6.3.3 --- The impact of missed dosage on clinical condition --- p.139 / Chapter 5.6.3.4 --- Practical issues regarding dosing frequency --- p.140 / Chapter 5.6.4 --- Drug Profiles --- p.141 / Chapter 5.7 --- Outcomes measure --- p.142 / Chapter 5.8 --- The role of pharmacist in chronic care --- p.147 / Chapter 5.9 --- The role of physician in chronic care --- p.155 / Chapter 5.10 --- Possible sources of bias and limitations --- p.156 / Chapter 5.11 --- Further studies --- p.156 / Chapter 5.12 --- Concluding remarks --- p.159 / Chapter 6. --- REFERENCES --- p.161 / Chapter 7. --- APPENDICES --- p.190

Background. Hypertension carries a high risk of cardiovascular complications. Patient medication non-compliance has been identified to be an major factor for suboptimal blood pressure control in clinical practice. Different strategies have been proposed to improve patient medication compliance but their effects on clinical outcomes were inconsistent. Methods . A telephone survey was conducted to examine patient medication compliance with anti-hypertensive drugs in Hong Kong. I then established a Pharmacist-managed Compliance Clinic in a public out-patient setting and provided individualized patient education to non-compliant patients identified by physicians. A telephone follow-up was arranged at 4-week after intervention followed by a more in-depth reassessment on subsequent physician clinic visit day. The immediate endpoint was patient compliance rate. Intermediate endpoint was systolic and diastolic blood pressure control. Other outcome measures were control of other cardiovascular risk factors and level of healthcare resources utilization. / Conclusion. Pharmacist-managed Compliance Clinic is effective in improving patient medication compliance and has positive impact on clinical outcomes. (Abstract shortened by UMI.) / Results. A total of 853 patients were successfully contacted and completed the patient survey. According to our definition, 80.4% of patients interviewed were considered to be compliant. Factors associated with medication compliance included multiple drug therapy, presence of drug adverse effects, patient's awareness of preventive nature of medication, rapport between patient and physician, and full-time working status. A causal model was successfully established with latent factors identified for medication non-compliance. The factors included patient's functional status, provision of health advice and concern from physician, and patient's knowledge regarding reasons for drug taking. Another two hundreds hypertensive patients were followed at the Pharmacist-managed Compliance Clinic. On average, each patient attended 1.3 pharmacist visits. The non-compliance rate fell from 100% to 20% after a single pharmacist intervention. Significant improvement was observed in patients' mean blood pressures readings as well as the diabetic and lipid control. Positive impacts on healthcare resources utilization were also observed. / Chan Man Chi Grace. / "June 2005." / Adviser: Juliana C.N. Chan. / Source: Dissertation Abstracts International, Volume: 67-07, Section: B, page: 3730. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2005. / Includes bibliographical references (p. 126-151). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract in English and Chinese. / School code: 1307.

末期腎衰竭乃是一種慢性並且會持續惡化的疾病，現時唯一的治療方案便是腎功能替代療法。在香港，一般新發現患有末期腎衰竭的病人，將會被安排進行持續性家居腹膜透析。接受持續性家居腹膜透析的病人均需遵照以下四項治療性方案(包括限制膳食和流質食物，服用處方葯物，及跟從腹膜透析的指引)，以減慢病程的惡化。以往有關病人遵照治療性方案的研究，大多側重於使用血液透析的病人及醫護專業人仕的評估。本研究的目的乃是從現正進行持續性家居腹膜透析的病人的觀點，去明白及解釋病人遵照治療性方案的模式。 / 此硏究採用混合方法硏究設計，並分兩期進行。在第一期的調查，173位病人自我評估其遵照治療性方案中四個環節的程度。調查結果顯示:參加對葯物及腹膜透析的遵照程度，比限制膳食和流質食物的遵照程度為高。再者，男性、較年青、或進行了透析治療一至三年的參加者，自覺其遵照程度比其他參加者為低。此調查結果將指導第二期硏究的最大變化採樣，方法是跟據參加者自我報告其遵照治療性方案的程度分為跟從及不跟從兩組，硏究採用立意取樣方法去選取36位不同性別、年齡、及透析年歷的參加者作第二期硏究的面談。整合第一期的調查及第二期的面談結果後，硏究為參加者遵照治療性方案的模式提供了解釋。 / 結果顯示參加者的遵照模式乃是一個浮動過程，此過程可分為三個階段: 起初的遵照模式、隨後的遵照模式、及長期的遵照模式。在起初的遵照模式階段，參加者嘗試嚴謹地遵照各項治療性方案，但體會到這是不能持久的。在進行了透析二至六個月後，參加進入隨後的遵照模式，透過試驗、監察及不斷的調校，參加者學會選擇性地去遵照某些治療性方案。當參加者接受透析三至五年後，他們開始進入長期的遵照模式，在這階段，參加者已能將自行修改了的治療性方案融入日常的生活當中。 / 參加者遵照治療性方案的浮動過程，乃是受其「抱怨失去自主及常規」和「嘗試挽回自主及常規」所驅使。此浮動情況在每個階段都會發生。除了透析年歷，影響參加者遵照治療性方案的決定性因素乃是其家人及醫護專業人仕的支持。參加並認為醫護專業人仕非常強調其需絶對遵照所有治療性方案，反眏現行以治療為本的照料模式。 / 此硏究在理論及臨床上皆有貢獻。在理論方面，此乃首個硏究確立接受持續性家居腹膜透析的病人，在遵照治療性方案的浮動過程中出現的三個階段。在臨床上，此三個階段的確立可作為策劃護理方案的參照，以幫助病人順利過渡各個階段。硏究的結果亦倡導醫療模式的轉變，即由以治療作主導的模式轉變為以病人為本的照料模式，授權病人在末期腎衰竭的治療過程中參與自我料理。 / End-stage renal disease (ESRD) is a chronic, progressive and debilitating illness with renal replacement therapy (RRT) as the only treatment modality. In Hong Kong, patients newly diagnosed with ESRD who require RRT are generally started on continuous ambulatory peritoneal dialysis (CAPD). Patients receiving CAPD are required to adhere to a renal therapeutic regimen comprising four components (dietary and fluid restrictions, and medication and dialysis prescriptions) to decelerate disease progression. Studies on patients' adherence have mainly focused on those undergoing haemodialysis and are generally from healthcare professionals' perspectives. The aim of this study was to understand and explain adherence from the perspectives of patients undergoing CAPD. / The study employed a mixed-methods design and was conducted in two phases. In phase I, a survey was conducted to examine 173 patients' self-reported adherence to the four components of the therapeutic regimen. Results showed that participants were more adherent to dialysis and medication prescriptions than to fluid and dietary restrictions. Moreover, participants who were male, younger or had received dialysis for 1 to 3 years rated themselves as more non-adherent than other participants. These findings guided the maximum variation sampling of 36 purposively recruited participants of different genders, ages, and duration of dialysis from the adherent and non-adherent groups for the phase II interview. The survey and interview data were merged in the interpretation of findings to provide an understanding of participants' adherence. / Findings indicate that participants' adherence was a dynamic process with three stages: initial adherence, subsequent adherence and long-term adherence. At the stage of initial adherence, participants attempted to follow instructions but found that strict persistent adherence was impossible. After the first 2 to 6 months of dialysis, participants entered the stage of subsequent adherence. Through experimenting, monitoring and making continuous adjustments, they learned to adopt selective adherence. The stage of long-term adherence commenced after participants had received dialysis for more than 3 to 5 years. At this stage, they were able to assimilate the modified therapeutic regimen into everyday life. / The dynamic process of adherence was driven by "grieving for the loss of autonomy and normality" and "attempting to regain autonomy and normality". The process was dynamic as there were fluctuations at each stage of the participants' adherence. In addition to the duration of dialysis, the major determinant influencing the participants' adherence was the support provided by family members and healthcare professionals. Moreover, participants perceived that the focus of care provision was on strict adherence to all components of the therapeutic regimen, reflecting a biomedical model of care. / This study has theoretical and clinical significance. Theoretically, this is the first study that identified three stages in the dynamic process of adherence among patients undergoing CAPD. Clinically, with reference to each stage identified, nursing interventions can be developed to help patients achieve a smooth transition throughout all the stages. The findings also call for a paradigm shift from the biomedical model of care to patient-centred care, so as to empower patients to engage in self-management of their ESRD. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Lam, Lai Wah. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2012. / Includes bibliographical references. / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract also in Chinese; some appendixes also in Chinese. / LIST OF TABLES --- p.xv / LIST OF FIGURES --- p.xvi / LIST OF ABBREVIATIONS --- p.xvii / LIST OF APPENDICES --- p.xviii / Chapter CHAPTER ONE --- INTRODUCTION / Introduction --- p.1 / ESRD and its management in the Hong Kong context --- p.2 / The research problem --- p.3 / Aim of the study --- p.6 / Overview of the thesis --- p.6 / Chapter CHAPTER TWO --- LITERATURE REVIEW / Introduction --- p.7 / Literature search strategies --- p.7 / The concept of adherence --- p.8 / Theoretical models used to understand adherence --- p.14 / Health belief model --- p.14 / Locus of control --- p.16 / Self-efficacy --- p.19 / Transtheoretical model --- p.22 / Measurement of adherence --- p.24 / Prevalence of adherence --- p.27 / Patients undergoing HD --- p.28 / Patients undergoing PD --- p.31 / Factors influencing patients’ adherence --- p.34 / Demographic and clinical characteristics --- p.34 / Social support --- p.37 / Knowledge about adherence --- p.39 / Chinese culture --- p.43 / Exploring adherence from patients’ perspectives --- p.47 / Adherence among patients undergoing dialysis in Hong Kong --- p.51 / An introduction to the concept of self-management --- p.52 / Summary --- p.53 / Chapter CHAPTER THREE --- METHODOLOGY / Introduction --- p.56 / Aim --- p.56 / Objectives --- p.56 / Operational definitions --- p.57 / Research design --- p.57 / The paradigm of mixed methods research --- p.58 / Justification for using a mixed methods design --- p.60 / Application of the mixed methods design --- p.61 / Phase I study --- p.67 / Sampling --- p.67 / Setting --- p.67 / Sampling method and sample size --- p.67 / Data collection method --- p.68 / Instrument --- p.68 / Data collection procedures --- p.70 / Data analysis --- p.70 / Pilot Study --- p.71 / Validity and reliability --- p.72 / Phase II study --- p.74 / Sampling --- p.74 / Sample size --- p.74 / Sampling method --- p.75 / Data collection method --- p.80 / Semi-structured interview --- p.80 / Development of the interview guide --- p.81 / Data collection procedures --- p.82 / Making contact with participants --- p.82 / The interviewing process --- p.83 / Data analysis --- p.87 / Pilot study --- p.89 / Rigour of the study --- p.91 / Credibility --- p.91 / Dependability --- p.95 / Confirmability --- p.95 / Transferability --- p.95 / Ethical considerations --- p.96 / Summary --- p.98 / Chapter CHAPTER FOUR --- FINDINGS OF THE PHASE I STUDY / Introduction --- p.99 / Results --- p.99 / Participants --- p.99 / Demographic and clinical characteristics of the participants --- p.100 / Overall adherence to the therapeutic regimen --- p.103 / Number of days non-adherent to the therapeutic regimen --- p.103 / Degree of deviation from the therapeutic regimen --- p.104 / Adherence in relation to demographic and clinical variables --- p.106 / Summary --- p.109 / Chapter CHAPTER FIVE --- FINDINGS OF THE PHASE II STUDY / Introduction --- p.110 / Demographic and clinical characteristics of the participants --- p.110 / Major categories and subcategories identified --- p.115 / Perceptions of adherence --- p.117 / Meaning of adherence --- p.117 / Perceived needs to adhere --- p.118 / Perceived levels of adherence --- p.120 / The process of adherence --- p.123 / Initial adherence --- p.124 / Practising two major types of adherence --- p.124 / Striving to live with strict adherence --- p.124 / Doing what I am told --- p.124 / Trying my best --- p.125 / Exercising self-control --- p.127 / Adopting partial adherence --- p.128 / Recognizing limitations of current types of adherence --- p.129 / Sacrificing freedom for strict adherence --- p.129 / Social restriction --- p.129 / Having nothing to eat --- p.132 / Paying the price of inadequate adherence --- p.133 / Physiological complications --- p.134 / Need for additional treatment --- p.136 / Harsh comments from healthcare professionals --- p.137 / Realizing the need for changes in adherence --- p.139 / Rationalising an easy-going approach to adherence --- p.139 / Seeing the need for stricter adherence --- p.144 / Subsequent adherence --- p.146 / Experimenting with an easy-going approach to adherence --- p.147 / Allowing some slippage --- p.147 / Monitoring indicators of adherence --- p.148 / Making continuous adjustments --- p.149 / Adopting selective adherence --- p.153 / Long-term adherence --- p.158 / Factors influencing the process of living with adherence --- p.159 / Support --- p.159 / Family members --- p.159 / Healthcare professionals --- p.163 / Hope for the future --- p.165 / Situational factors --- p.168 / Dinning out --- p.169 / Employment --- p.171 / Summary --- p.173 / Chapter CHAPTER SIX --- DISCUSSION / Introduction --- p.177 / The dynamic process of adherence --- p.179 / Initial adherence --- p.182 / Following instructions --- p.182 / Grieving for the loss of autonomy and normality --- p.184 / Social restriction --- p.185 / Unmet nutritional and psychosocial needs --- p.187 / Subsequent adherence --- p.193 / Experimenting with an easy-going approach to adherence --- p.193 / Attempting to regain autonomy and normality --- p.198 / Dialysis --- p.199 / Medication --- p.201 / Fluid --- p.204 / Diet --- p.205 / Long-term adherence --- p.209 / Support as a major determinant of adherence --- p.212 / Family --- p.213 / Healthcare professionals --- p.216 / Biomedical model of care --- p.221 / Disease-oriented perspective --- p.222 / One-way paternalistic communication --- p.228 / Summary --- p.232 / Chapter CHAPTER SEVEN --- CONCLUSIONS / Introduction --- p.235 / Limitations of the study --- p.235 / Implications --- p.237 / Implications for clinical practice --- p.237 / Initial stage --- p.237 / Provision of timely appropriate support --- p.238 / Psychological support --- p.238 / On-site support --- p.239 / Adjustment of the CAPD training content --- p.240 / Empowering patients for self-management of their ESRD --- p.241 / Subsequent stage --- p.244 / Long-term stage --- p.245 / Implications for administration --- p.246 / Implications for nursing education --- p.247 / Recommendations for further research --- p.249 / Conclusions --- p.252 / REFERENCES --- p.254