Clinical characteristics. Measures were also taken of the clinical severity of the heart
attack (congestive heart failure, severity of heart attack, age) and sociodemographic
features (ethnicity, marital status, education).
Mortality. Mortality was measured after 12 months.Results
Adherence and mortality
The results were analysed to examine the relationship between adherence and
mortality, and showed that, compared with patients with good adherence, those with
poor adherence were twice as likely to have died at one-year follow-up. This association
was also present when the data were analysed according to treatment category (i.e. for
both the experimental group and the control group). Therefore, regardless of what
the drug was (whether a beta-blocker or a placebo), taking it as recommended halved
the subjects’ chances of dying.The role of psychosocial and clinical factors
The results showed that death after one year was higher for those subjects who had a
history of congestive heart failure, were not married, and had high social isolation and
high life stress. In addition, those who had died after one year were more likely to have
been smokers at baseline and less likely to have given up smoking during the follow-up.
However, even when the data were analysed to take into account these psychosocial and
clinical factors, adherence was still strongly associated with mortality at one year.Conclusion
These results therefore indicate a strong link between adherence to medical recom-
mendations and mortality, regardless of the type of drug taken. This effect does not
appear to be due to psychosocial or clinical factors (the non-adherers did not simply
smoke more than the adherers). Therefore ‘doing as the doctor suggests’ appears to be
beneficial to health, but not for the traditional reasons (‘the drugs are good for
you’) but perhaps because by taking medication, the patient expects to get better. The
authors concluded in a review article that ‘perhaps the most provocative explanation
for the good effect of good adherence on health is the one most perplexing to clinicians:
the role of patient expectancies or self efficacy’. They suggested that ‘patients who
expect treatment to be effective engage in other health practices that lead to improved
clinical outcomes’ (Horwitz and Horwitz 1993). In addition, they suggested that
the power of adherence may not be limited to taking drugs but may also occur with
adherence to recommendations of behaviour change. Adherence may be a measure of
patient expectation, with these expectations influencing the individual’s health status –
adherence is an illustration of the placebo effect and a reflection of the complex
interrelationship between beliefs, behaviour and health.318 HEALTH PSYCHOLOGY