Simulating Human Carer with an Avatar to Improve Medication Adherence Kerry Y. FANG a,1 , Heidi BJERING a and Athula GINIGE a a School of Computing, Engineering, and Mathematics, Western Sydney University, NSW, Australia Abstract. Non-adherence to medication and treatment regimens is considered as a major issue in the healthcare industry as it can lead to negative consequences. Var- ious strategies have been applied to improve adherence, however many of these strategies lack the interaction and personalisation-aspect which has been shown to be crucial to the patients. This paper discusses the importance of personalised in- teraction in improving patients’ medication adherence, and the character istics needed in an avatar to simulate such human-human interactions. Keywords. Medication adherence, avatars, patient communication Introduction Adherence to medication and treatment regimens is a growing concern worldwide, as non-adherence can result in negative consequences to the patients and the healthcare industry. Factors that affect an individual’s adherence to medication regimens can be categorised into three groups: medication-related factors, patient-related factors, and other factors such as patient-doctor relationship, and social support [1]. Various strategies have been developed and applied in order to improve medica- tion adherence. SMS and phone apps are currently the most trending and widely-used strategies, along with other traditional and modern approaches. Interaction is said to be crucial to the community, especially for the people who live alone, as they sometimes become isolated and socially disconnected which can affect their adherence [2]. How- ever, many of the current strategies do not provide personalisation where information is designed tailored to each user, and many also use one-way communication, which means it lacks the two-way interaction to socially communicate with the users. The focus of this paper is on the use of avatars to aid medication adherence. This paper reviews current literatures on strategies to improve adherence from the patient’s point of view, particularly patient communication strategies, with the aim to identify the social and communicative aspects of human carers and doctors that are important for adherence, and to discuss the characteristics of an avatar to simulate human behav- iours in order to achieve a comparable outcome in improving adherence. 1 Corresponding Author: Kerry Y. Fang, PhD candidate, Western Sydney University, NSW, Australia. Email: 16730250@student.westernsydney.edu.au.
1. Background of Adherence Medication adherence is defined as the ability and willingness to abide by a prescribed therapeutic regimen [1]. Medication adherence is a global issue as inconsistent and interrupted adherence behaviour can result in negative consequences to the patients and the healthcare system. Studies have shown that the rate of medication adherence in developed countries is only about 50% [2, 3], and even less in developing countries. Various factors can influence adherence, and these can be categorised into medication- related factors, patient-related factors and other factors [1]. Medication-related factors include medication regimen, adverse effect, and the number of concurrent medications [1]. Patients with a medication regimen that exceed twice daily episodes are found to have a decreased adherence [4]. Fear of adverse ef- fects is one of the most common reasons of intentional non-adherence. The effect of side effects may be explained in terms of physical discomfort, skepticism about the efficacy of the medication, and decreasing the trust in clinicians [5]. Patient- related factors can also affect adherence. These include the individual’s cognitive ability, health knowledge and beliefs, and physiology of the patients [1]. Pa- tients that understand their condition, their need for treatment, and those that believe in their medication often have a better adherence [6]. The Health Belief Model was devel- oped to describe how patients were more likely to adhere to their medication and treat- ment regimen when they feel susceptible to the illness, believe that the illness will have potential serious consequences to themselves, and did not anticipate major obstacles such as adverse effects [7]. Age can also influence adherence; functional and cognitive decline and the need for multiple medications are the major reasons for non-adherence in the elderly population [8]. Other factors that can affect adherence include patient-doctor relationship, access to medication, past experience of illness, and social support [1]. Within these, the pa- tient-doctor relationship is considered crucial in improving adherence [9-12], and such relationship will be discussed in detail below under “Patient communication”. Most of these adherence-related factors can be addressed by the use of an avatar, especially those that are patient-related. For example, an attentive, knowledgeable and motivative avatar can help a patient who has fear of side effects by answering the pa- tient’s concerns, motivate them, and provide detailed knowledge/information in regards to the medication they take. More detail about the use and characteristics of an avatar to improve adherence will be discussed in detail later in the paper. 2. Strategies to Improve Adherence Many strategies have been developed and applied in order to help improve adherence towards medications. Traditionally, healthcare professionals often use a combination of strategies to improve medication adherence [13]. One of the most commonly used tra- ditional adherence aids is the weekly pill box, which has separate compartments for patients to put their medications [2]. Dose modification is a strategy used by healthcare professionals to improve pa- tients medication adherence by planning a medication schedule that best suits the needs and lifestyle of each patient [14]. “Forgiving drug” is another strategy that is used on patients that tend to skip or delay their medication doses, especially for long term ill- ness [15]. These drugs have a prescribed dosage interval that is 50% or less the dura-
tion of the drug action, which means if occasional doses are missed, the drug action will still be able to continue with at least 50% strength until the next scheduled dose [2, 15]. With the rapid development in technologies, newer products and tools utilising computer technology have been developed in order to identify and improve adherence. Some of the popular ones include the use of mobile phone reminders, in-home electron- ic reminders, and portable reminders. Mobile phones allow constant access to communication and information. They provide ubiquity, accessibility, and familiarity for users, which in turn has the potential to make their long term use more sustainable over other electronic devices [16]. Studies have shown that mobile phone based reminders, such as SMS service and reminder applications, contributed positively to improving medication adherence [16, 17]. Reminder services can also be built into home environments, such as smart homes, for better health management and monitoring purposes. An example of this is the au- tomatic pill dispensers, which are computer-based monitoring systems that can be pro- grammed to emit audible or visual alarms, separating medications into compartments and dispensing the correct dose at the scheduled time [18]. Portable reminder devices, such as the electronic pill box, have an advantage over in-home reminder devices due to their portability which makes them especially popular amongst busy individuals. These devices often work by sounding an alarm to remind patients to take their medications [19]. 3. Patient Communication The discussion above highlighted some of the most commonly used strategies to im- prove adherence. However, many of these lacks personalised interaction, which has been found to be a crucial aspect in improving medication adherence [20, 21]. This can be achieved through patient-doctor relationships by modifying beliefs and human be- haviour, and even involving patients’ families in the dialogue. The patient-doctor relationship is based on patient’s trust in the doctors and empa- thy from the doctors. A study has found that adherence is good when doctors are emo- tionally supportive, giving reassurance or respect, and treating patients as an equal partner [9]. Good communication of instructions and information provided by healthcare professionals to patients is associated with better adherence and lower medi- cation errors, and is often considered as a fundamental condition to be satisfied by healthcare professionals [10, 1 1]. A study has shown that doctor’s friendliness and ap- proachability, encouragement of doctor-patient cooperation, enhancement of patient- centeredness, improvement of doctor’s teaching skills, and taking into account the spir- itual and psychological dimensions are especially important to patients [12]. Well-educated patients that understand their illnesses and medication requirements are more willing to follow the prescribed regimen. A study has shown that patients’ understanding of their conditions and treatments is positively related to adherence, and this is related to that some patients do not understand prescription instructions [21]. Doctors can provide effective patient education by using simple and everyday language when explaining health diagnosis and giving instructions to the patients [22]. For com- plex medication regimens, especially those that require lifestyle modifications, it is also important to address the patient’s beliefs. This is because knowledge alone isn’t suffi- cient to improve adherence in situations that require complex behaviour change [23].
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