Treatment burden and treatment fatigue as barriers to health
Section snippets
Chronic disease and health behaviors
The leading causes of chronic disease and preventable death are attributed to modifiable risk behaviors [1], such as minimal physical activity, poor nutrition, tobacco use, and overconsumption of alcohol. Although numerous interventions have been found to promote health behaviors within clinical trials, these often fail to translate into sustained, real world effectiveness. This disconnect has been attributed, in part, to poor adherence to self-administered treatments (e.g. medication,
Treatment burden
The science of treatment burden has advanced substantially since 2012. Several qualitative studies have been conducted to conceptualize patient concerns [10], [11], and examine how well these are addressed by primary care providers [12]. These studies are complemented by systematic reviews of studies that examined treatment burden both qualitatively [13], [14] and quantitatively [15•], [16]. Studies reviewed rarely focused on treatment burden specifically, but a priori definitions of burden
Treatment fatigue
Beyond assessment of treatment burden (i.e. how much effort is required for a given health behavior), a growing area of interest focuses on the impact of that burden. There is extensive research on physical fatigue caused by specific interventions (e.g. chemotherapy among cancer patients), but we focus on the psychological fatigue associated with treatment engagement, herein called treatment fatigue. This nascent literature is mostly restricted to diabetes and human immunodeficiency virus (HIV)
Integrative model and clinical implications
The treatment fatigue literature within diabetes and HIV both point toward the need for common terminology, definition, and measurement tools. A broader conceptualization of fatigue, across a range of chronic health behaviors, would facilitate a transdiagnostic understanding. Our workload–capacity model (Figure 1) incorporates the evidence that treatment fatigue may, firstly, be caused by increased workload due to treatment burden (e.g. intensity, complications) and secondly, undermine
Potential applications
With the exception of one study [29••], the concepts of treatment burden and fatigue have not been applied to understand the most common sources of morbidity and mortality: obesity, nicotine dependence, or alcohol dependence. These are chronic and relapsing conditions that require substantial effort to change, and may be susceptible to the same patterns described above. It is unclear if burden and fatigue will manifest differently when attempting to change behaviors that are hard to reduce
Future of chronic care
Behavioral intervention technologies offer scalable approaches to reduce patient efforts [33], [34], [35], [36], and are evolving rapidly [37], [38], [39]. Mobile phones are owned by 90% of American adults [40], representing a platform to increase accessibility to chronic care. Mobile health interventions (mHealth) can facilitate communication between health care providers and patients, thereby reducing burden associated with travel (e.g. transportation costs, time). Although mHealth has
Conclusions
Chronic disease management requires substantial effort, and is associated with both positive and negative consequences. The balance between patient demands and capacity may be indexed by treatment fatigue, and will determine the sustainability of the behavioral change (i.e. adherence). This suggests the need for ongoing efforts to reduce treatment burden and/or increase patient capacity to undertake necessary health behaviors. Innovations in technology-based interventions (e.g. mHealth) are
References and recommended reading
Papers of particular interest, published within the period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Conflict of interest
None declared.
Acknowledgements
Funding for this research was provided by National Institute on Drug Abuse awards T32 DA007288 (BWH), and F32 DA036947 (ARM).
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