Methods Section Combined

Effect of Adherence on Psychological Outcomes
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Institution

Best practice in healthcare is based on empirically proven treatment modalities. One aspect of treatment that is presumed to yield better outcomes is adherence to treatment. However, this aspect of treatment has been emphasized in medication treatments. Patients across the spectrum of diseases have shown issues with adherence to treatment, calling for a need to investigate the factors that impede this adherence. On the other hand, there has been minimal attention on the health care effects of this adherence. Often, it is presumed that better adherence would yield better outcomes, there is no study indicating the extent of positive outcomes that would be derived from such behavior.
The concept of ‘adherence’ in general medicine has received more attention, unlike in the field of psychology. Gonzalez and Williams (2006) indicated that the limited focus on adherence in psychological treatments is due to the varied approaches that are characteristic of these treatments. Unlike medicine, psychological therapy views adherence in reference to dropouts; yet, medication treatments characterizes adherence in terms of visits; hence, when conducting this study, it is important to operationalize the term adherence. The varied approaches; thus, indicate the different and inconsistent effect of adherence. As a result, there is need to conduct studies that will help to develop a standardized definition of the word. Also, most studies in psychology have examined adherence as an outcome of treatment, unlike the current study that aims to look at adherence as a predictive factor.

There have been various studies that have sought to investigate the effects of adherence on health care outcomes, most of which are old and a few are not specific to psychological disorders. Horwitz and Horwitz (1993) indicated that adherence is associated with positive outcomes but adherence calls for more than taking a particular medication, but it is also associated with “nonspecific therapeutic effects” where mental health might be part (Horwitz & Horwitz, 1993, p. 1863). Depression has been one comorbid that has shown to emerge and coexists with other ailments and especially when the course of treatment is not associated with a good prognosis.
Depression is believed to occur when treatment does not produce beneficial outcomes, but it can occur as an independent entity. Gonzalez and Williams (2006) state that this disorder is associated with low adherence levels to treatment when it coexists with another ailment like diabetes. However, it is unclear whether the disorder would produce similar effects when it exists solely as a psychological ailment. Grenard et al. (2011) have suggested a similar trend due to a myriad of risk factors linked to non-adherence among individuals with coexisting ailments that include depression. There are various studies that indicate various interventions that can be applied to increase adherence among individuals with depression, but it is unclear whether they would produce expected adherence levels as shown in these studies.
There is adequate research on the factors that influence adherence to treatment, and a substantial amount of research investigations have been carried out to develop strategies meant to increase adherence and presumed associated effects. There are limited studies that have focused on adherence interventions in depression which could be due to the various psychological disorders and each seems to require specific interventions. In reference to psychological disorders, individuals have a negative perception about these disorders because patients think that they are being considered “mad/crazy”; hence, they are likely to deviate from the normal course of treatment.
In a more recent study by Hogue et al. (2010), the impact of adherence on treatment outcomes was based on certain predefined outcomes. In addition, the treatments under investigation were cognitive-behavioral therapy (CBT) and multidimensional family therapy (MDFT). This study was conducted among a group of adolescents who had been diagnosed with substance use and abuse. Thereby, the outcomes under investigations were limited to timeline follow-back, eternalizing and internalizing symptoms, and the severity of the substance use problem using a personal experience inventory. However, this study aims at focusing on depression, which has received the least attention in relation to adherence. Also, this study will target the care givers because most of the individuals with depression are not in a position to answer research questions.
It, therefore, follows that adherence is an important aspect of effective treatment, but it has been viewed differently in psychology as opposed to general medicine. Using a more holistic approach to adherence, there is need to carry out a study that examines their effect on depression because this aspect of treatment has rarely been studied in this population. Hence, the purpose of this study will be to determine the effects of adherence on treatment or healthcare outcomes among individuals between 45 and 65 years with depression using a quasi-experimental design. Hence, the guiding research questions will be:
What strategies can be used to promote total adherence to treatment among individuals with depression?
How does adherence improve psychological treatment outcomes?
The hypotheses to be tested will be:
H01: There is no relationship between adherence strategies and depression scores
H02: There is no relationship between adherence and improved treatment outcomes

Methods Section
Research Design
This study will adopt a quasi-experimental research because it will entail collecting data before and after an intervention. This research design is a powerful approach towards establishing a cause and effect relationship between variables. This kind of research design was used to help develop a more credible cause and effect relationship in a population that is not ethically feasible to carry out a randomized controlled trial (Harris et al., 2006). Thereby, since it is not possible to have a control group that does not adhere to treatment because such a move would be deemed harmful to the subjects. Quantitative data will be collected with a focus on adherence levels as the independent variable and treatment outcomes as the dependent variable.
Participants
Individuals will be recruited from the psychological unit of X hospital. The sample size will be determined using sampling tables as indicated Dessel (2013). Thereby, presuming that the list of identified patients is 100, using this sampling table, a sample size of around 80 participants would be used. This sample size is in reference to a confidence level of 95% and a margin of error of 5%.
Individuals will be enrolled using stratified random sampling with guidance from the list of individuals identified as poorly adhering to treatment. The sample will include individuals with depression, only; hence, individuals with other comorbidities will be excluded because the effect of these comorbidities might introduce bias due to their confounding effect. Participants will be restricted on the basis of age because only individuals between 45 and 65 years old will be included in the study. However, there will be no restriction in reference to gender and ethnicity because it will help to devise understand the population better. The age of the participants was purposively selected based on physical development; this is a time when exposures of life take a toll on their health.
Research Setting
The study will be conducted in a hospital set-up, and specifically, the psychological unit within that hospital. The hospital setting was selected because individuals are likely to make contact with a hospital when something is wrong than any other institution. Thereby, the researcher is likely to find the required sample here.
Procedure
Individuals who have not adhered to treatment will be identified and a list developed to aid in sampling. This will be followed by the collection of baseline data on the health status of the participants in reference to the treatment outcomes of interest. The elements of interest will include internalizing and externalizing symptoms, quality of life, and depression scores. Afterwards, all participants will be subjected to different strategies believed could help participants attain a high level of adherence. Adherence will include abiding to set appointments and completing given assignments in time. Individuals will be randomly assigned to different groups where each group will be subjected to certain adherence strategies to help overcome some of the barriers and encourage total participation in their therapy. In one group, the strategies were standardized and based on previous literature; they included psychoeducation, financial support, reminders, provision of transport when necessary and home visits for follow-up. The interventions in the other group were customized to the specific needs of each patient. Individuals, through their caregivers, noted the barriers to adherence, and each individual received unique support services related to the barriers specific to him or her. The interventions to encourage a high level of adherence proceeded for one month. Afterwards, a post-test will be conducted and results compared with baseline data. This study relies on the assumption that the participants with depression are not in a capacity to answer research questions; therefore, accompanying caregivers will be interviewed instead.
Research Instruments
A questionnaire to assess adherence levels and treatment comes will be developed. The questionnaire will be developed by reviewing previous literature reviews and similar instruments to come up with one that is relevant to the current study. The questionnaire will be assessed for face validity through the help of experts in the field, including the supervisor for this study. This review will ensure that the questions making up the questionnaire are related to the objectives; thus, data collected will be of use in testing the hypotheses. Reliability will be determined by disseminating to a group of individuals with a different ailment twice and the Cronbach alpha obtained where a correlation coefficient from 0.7 is considered satisfactory according to Leung (2001).
Data Analysis
SPSS will be used to help in data analysis. The population will be described using mean, mode, median, and percentages to understand its characteristics in reference to sociodemographic and economic domains. Chi-Square and ANOVA will be used to determine statistical difference between treatment outcomes before and after the home visits and follow-up calls depending on the kind of variable. Nonetheless, the alternative non-parametric tests will be used if a normalcy test indicates that the sample is not normally distributed. Thereby, significant differences will ascertain the efficacy of high treatment adherence when the goal is to attain positive treatment outcomes.
Ethical Considerations
Participants will participate in the research voluntarily, and this will be proved by the participants’ signature on the informed consent form. Permission to carry out the research will be obtained from the healthcare facility after gaining ethical clearance from the university.

References
Dessel, G. V. (2013). How to determine population and survey sample size? Retrieved from https://www.checkmarket.com/blog/how-to-estimate-your-population-and-survey-sample-size/.
Gonzalez, J., & Williams, J. W. (20016). The effects of clinical depression and depressive symptoms on treatment adherence. In H. B. Boswoth, E. Z. Oddone, & M. Weinberger (Eds.), Patient treatment adherence: Concepts, interventions, and measurement. London: Lawrence Erlbaum Associates.
Grenard, J. L., Munjas, B. A., Adams, J. L., Suttorp, M., Maglione, M., McGlynn, E. A., & Gellad, W. F. (2011). Depression and Medication Adherence in the Treatment of Chronic Diseases in the United States: A Meta-Analysis. Journal of General Internal Medicine, 26(10), 1175–1182.
Harris, A. D., McGregor, J. C., Perencevich, E. N., Furuno, J. P., Zhu, J., Peterson, D. E., & Finkelstein, J. (2006). The Use and Interpretation of Quasi-Experimental Studies in Medical Informatics. Journal of the American Medical Informatics Association : JAMIA, 13(1), 16–23.
Hogue, A., Henderson, C. E., Dauber, S., Barajas, P. C., Fried, A., & Liddle, H. A. (2008). Treatment Adherence, Competence, and Outcome in Individual and Family Therapy for Adolescent Behavior Problems. Journal of Consulting and Clinical Psychology, 76(4), 544–555.
Horwitz, R. I., & Horwitz, S. M. (1993). Adherence to treatment and health outcomes. Archives of Internal Medicine, 153(16), 1863-1868.
Leung, W. (2001). Statistics and evidence-based medicine for examinations. Newbury: LibraPharm Limited.