The Effects of a Spouse Implemented Contingency Contract on Asthma Medication Adherence

Asthma prevalence, morbidity, and mortality in the United States have increased during the past decade despite major national efforts to improve asthma awareness and care (Centers for Disease Control and Prevention, 1998). One cause of this increase may be asthma medication non adherence. Asthma sufferers' adherence to asthma medications is very low. Asthma sufferers are less likely to adhere to their medication regimen if the asthma symptoms are either mild or severe, if the medication is expensive, and if the medication side-effects are aversive (Cramer & Spilker, 1991). Several studies have compared participants' self-report with direct measures (e.g., urine testing, pill counting) of medication adherence, and overall these studies suggest that adherence ranges between 10% and 60% (Spector, 2000). Applied behavior analysts have proposed various factors for improving adherence to treatment regimens and have repeatedly shown that adherence responds to properly managed contingencies (Allen & Warzack, 2000). Contingency management systems have been used to increase adherence in a variety of settings, such as schools, communities, and medical settings. Da Costa, Rapoff, Lemanek, and Goldstein (1997) provide one example where a parent effectively implemented a contingency management system to increase asthma medication adherence of two children. The intervention included asthma education and a token system. The token system involved the children earning points for medication adherence and exchanging the points for privileges. Failure to take the prescribed medications resulted in a loss of privileges for one day. However, a spouse-implemented contract on asthma medication adherence by an adult spouse has not been analyzed. Hence, the present study is an extension of da Costa et al. (1997) in that similar techniques (e.g. contingency contract, pulmonary readings) were employed, except the participant dyad was a husband and wife instead of a parent and child. The purpose of this study was to (1) analyze the effectiveness of a contingency contract on asthma medication adherence, (2) to evaluate the effect of transferring contract implementation to the husband and (3) to observe maintenance during nine months of follow-up probes. In addition, the study measured the participant's pulmonary functioning to assess the effect of asthma medication adherence. Method Participants and Setting The participants were Tracy, a 30-year-old woman with asthma and her husband, George. They responded to an ad placed in the local grocery store. Tracy had long-lasting physician-diagnosed asthma symptoms and was non-adherent with her asthma medication regimen. Tracy reported that she was non-adherent because she concluded that irrespective of the medications she took, she would not feel better. Tracy reported having periodically taken her asthma medication without decreasing the frequency, duration, and discomfort elicited by the asthma attacks. The first author, a graduate student, performed this study. Tracy and George's living room served as the setting. Tracy and George signed an informed consent form prior to the start of the study. Response definition The researcher used an electronic monitor to observe Tracy's adherence to a medically prescribed regimen. The regimen prescribed inhaling one dose of Serevent every morning and another dose every evening. The researcher measured adherence by an electronic chronology monitor called a Doser[TM] that attached to the Serevent canister and recorded the number and date of each actuation. Doser-recorded actuations could be displayed on an LCD panel, and stored in memory. The researcher considered Doser readings to be reliable when Tracy's, George's and the researcher's number of Doser recorded actuations matched. For example, the researcher, Tracy and George would individually write down the number located on the LCD display and the three numbers would be compared. …