Degree Name

Doctor of Philosophy


School of Psychology


Patient nonadherence to prescribed medications remains a major hurdle in the effective delivery of health care services for people experiencing chronic illnesses. Nonadherence rates are particularly high among those with major mental health problems and account for a significant proportion of hospitalisations due to relapse in conditions previously well-managed by medications. Therefore, interventions to enhance the adherence of patients with mental health disorders should be an essential part of mental health services; however this is not always the case. This thesis involved a series of studies which investigated barriers to the implementation of adherence interventions, in particular, clinician skills, attitudes and knowledge, as well as describing a potential strategy to overcome these barriers. The first study investigated the relationship between the beliefs and knowledge mental health nurses hold about medications and how this influences their self-reported use of strategies to enhance patient adherence to treatment. Participants comprised a convenience sample of 64 mental health nurses who completed questionnaires on their beliefs about medicines, their knowledge of neuroleptic medications and their self-reported difficulties in using commonly cited strategies for enhancing patient adherence. The results indicated that both poorer knowledge and more negative attitudes were associated with greater perceived difficulty in implementing standard adherence strategies. The first study provided the impetus for a closer examination of specific clinician attitudes in relation to working with non-adherent patients and how such attitudes might influence clinician behaviour. Study 2 was a cross-sectional anonymous survey of 292 mental health clinicians and explored their attitudes about nonadherence in patients. Exploratory and confirmatory factor analysis of the attitudes items produced a 19 item, 5 factor scale: the Medication Alliance Beliefs Questionnaire (MABQ). The MABQ subscale ‘Adequacy’, (beliefs about the the sufficiency of the clinicians’ own knowledge and skills in working with people who have nonadherence issues), was found to predict the extent to which mental health clinicians tried to enhance patient adherence. The first two studies identified deficits in clinician skills, knowledge and attitudes as significant barriers to the implementation of adherence interventions. A clinician training program called “Medication Alliance” was then developed which specifically targeted skills, attitudes and knowledge relevant to the enhancement of patient medication adherence. Study 3 provided an initial evaluation of this training program in terms of the extent to which clinician participants showed improved skills, had enhanced knowledge and more positive attitudes toward working on adherence issues (using the MABQ). Participants were 23 experienced mental health workers who worked actively with non-adherent patients. The results indicated pre-post training improvements in all three domains (skills, knowledge and attitudes). The first three studies identified the barriers to the implementation of adherence interventions, (clinician skills, knowledge and attitudes), and demonstrated that the Medication Alliance training program could improve these three clinician domains. Study 4 sought to determine whether Medication Alliance could be implemented in practice by clinicians and whether this resulted in improvements in patient adherence and reductions in levels of mental ill-health. A total of 46 clinicians participated in an ‘implementation trial’ of Medication Alliance, with 51 patients providing clinical data. Data was collected at baseline, 6 months following clinician training and then again at 12 months post training. As with Study 3, improvements in clinician knowledge, attitudes and skills coincided with training. In an extension of these findings, most of these improvements were maintained over a 12 month period. It was also shown that clinicians’ ratings of patients’ adherence and their rating of therapeutic alliance also increased over the 12 month period. Patients demonstrated improved insight into the need for treatment and reduced psychopathology. Overall, the results of Studies 1 through 4 indicated that clinician’s attitudes are an important consideration in implementing adherence strategies and that these attitudes can be successfully improved as a result of training. Further, preliminary research suggests that clinicians can learn, sustain and implement skills to facilitate medication adherence in their patients. Finally, these training effects appear to be associated with improvements in adherence and mental health in patients. Although results from these implementation studies are encouraging, there is a need for a randomised clinical trial of Medication Alliance training compared to treatment as usual or a viable comparison intervention.

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