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Friday, September 01, 2006

Examples of and Reasons Why Patients do not Adhere.Examples of and Reasons Why Patients do not Adhere.

Aherence (or compliance) in health care takes two main forms: behavioural and medical. The former is concerned with health behaviours such as quitting smoking and the adoption of exercise. Medical compliance can take a variety of forms and include those which are concerned specifically with medication including: having prescriptions filled, taking the correct dosage, taking the medicine at the correct times, remembering to take one or more doses and stopping the medication on time (Whitney et al., 1993).

Why don't patients adhere?

Patient characteristics.

Meichenbaum and Turk (1987) identify these patient characteristics with non-adherence -

Social Characterisitcs; lack of social support, parental expectations and attitudes towards treatment, competing or conflicting demands, lack of resources.

Personal Characteristics; type and severity of psychiatric disorder, forgetfulness, lack of understanding.

Health Beliefs; competing social and cultural concepts of disease and treatment, inappropriate or conflicting health beliefs.

Treatment Factors.

Obviously the type and nature of the treatment being offered will have a significant impact on how likely patients are to adhere. Meichenbaum & Turk (1987) summarise treament factors that are likely to lead to non-adherence as follows -

Preparation for Treatment; inconvenience associated with operation of clinics, lack of cohesive treatment and delivery, long time between referral and appointment, long waiting times.

Immediate Character of Treatment; complexity of treatment regime, duration of treatment, degree of behavioural change required, inconvenience. For example, of 170 leaflets reviewed by Ley (1982) and Ley and Morris (1985), only 15% could be understood by 75% or more of the population. This led Ley and Florio (1996) to suggest the use of readability formulas in the development of written health information materials. Besides complexity, an important treatment characteristic is the actual length of the treatment regimen. Hulka et al. (1976) found that compliance declined with length of the treatment regimen. Though this may be due to the lack of visible symptoms that is often associated with long term illness, or the lack of rapid improvement of noticable symptoms, rather than the length of treament per se.

Administration of Treatment; inadequate supervision by health workers, absence of continuity of care, parents not supervising drug use.

Consequences of Treatment; medication side effects, social side effects (stigma, labelling, etc).

As you can see this means that there are numerous factors that can easily contribute to non-adherence. This may be why non-adherence is so high.

Interpersonal Factors.

DiNicola and DiMatteo (1982) suggested that patients are more compliant if their physician is warm, caring, friendly and interested. In behavioural terms the doctor keeps good eye contact, smiles a lot and leans in towards the patient - all behaviours which are interpreted as demonstrating interest and consideration. Further, Hall et al. (1988) found in their meta-analysis of 41 studies that patient satisfaction was associated with perceived interpersonal competence, social conversation and better communication as well as more information and technical competence. Thus we can conclude that the more satisifed a patient is with their relationship with their doctor, the more willing they are to adhere to the medical advice given.

An additional point is that the more understanding the physician of the patient's belief system, the more compliant the patient is. For example, Ruiz and Ruiz (1983) found that Hispanic patients tend to comply more when their doctor is more understanding of their cultural norms and practices.

Non-Adherence as a Rational Process.

To illustrate some of the points above and to show that non-adherence is not always patients just willfully being 'bad patients', a study is detailed below which has argued that to understand why patients do not always do exactly as their doctor tells them is because of their lived experience of being ill.

Conrad (1985). Over a three-year period he conducted interviews with 80 individuals who had epilepsy about their life experiences with the disease. He noted that the individuals developed a personal 'medication practice' which best fitted with their self-image and their lifestyle. The patients realized the benefits of medication for seizure control and frequently stated that the medication helped them be more 'normal'. However, simultaneously the medication was seen as a daily reminder that they had epilepsy. They felt that reducing the medication was evidence that they were 'getting better'. Side effects were a frequently given justification for not complying with the recommended treatment. However, although side ects were mentioned they rarely referred to bodily side effects. Rather, they referred to social side effects. If the people with epilepsy felt that the medication was impairing their ability to handle routine social activities, they modified the medication to reduce this impact.

Conrad identified four main reasons for non-adherence in the Ps of his study. These were -

  • Testing: the way patients test the impact of varying dosages.
  • Controlling dependence: the way patients assert to themselves and others that they are not dependent on the prescribed medication.
  • Destigmatisation: an attempt to reject the illness label and to be 'normal'.
  • Practical practice: the way patients modified their dosage so as to reduce the risk of seizures, e.g. increasing the dosage in high stress situations.

Therefore we can conclude that non-compliance is a rational process whereby the individual carefully adjusts the medication to maximize its impact.

(Cited in Marks et al, 2000)

Measuring Adherence

There are a variety of different ways that we can evaluate compliance -

Use the Doctors' Judgment. However doctors are notoriously poor at determining whether or not their patients have used medications.

Trust Patient's Self-Reports. Researchers are divided as to whether or not they believe self-reports. When patient reports have been compared to some objective measure of medicine taking, studies have tended to show that patients are accurate when they claim that they have not taken their medication. However, for those who claim that they have used the medication as prescribed, these verbal reports are often not confirmed by objective records (Spector et al., 1986).

Use of Objective Measures. For example, you can count pills, check pharmacy records, or weigh medicine containers that are used to distribute liquid medications. Using these methods requires that you understand exactly how much medicine the doctor had prescribed. There are also a variety of different problems that can lead to inaccurate assessments. For example, medications are often shared by other members of the household, given to friends, or simply dumped out. This is more true for particular types of medications such as tranquilizers and sleeping pills.

Use of Biochemical Analysis. Some medicines can be followed by examining blood, urine, or other bodily excretions. Sometimes a pharmacist can put a "marker substance" in the medication. Riboflavin, for example, can be added to medication as a method of tracking its use. There are other biochemical by-products that can be studied. For example, smokers can be detected by studying carbon monoxide in their blood or exhaled breath. Smoking can also be followed using tests for metabolites for nicotine. One of these is called cotinine. Although biochemical measures of compliance are attractive for the sake of accuracy, there are also some problems. For example, these measures often produce misleading findings. For instance, thyocynide, which is often used to evaluate cigarette smoking, can also be affected by other aspects of the Ps diet. Cabbage, for instance, increases thyocynide concentrations.

(Cited in Kaplan et al, 1993)

Improving Adherence

Providing Information

Ley (1989) suggested that one way of improving compliance is to improve communication in terms of the content of an oral communication. He believes the following factors are important:

  • primacy effect - patients have a tendency to remember the first thing they are told;
  • to stress the importance of compliance;
  • to simplify the information;
  • to use repetition;
  • to be specific;
  • to follow-up the consultation with additional interviews.

Researchers also looked at the use of written information in improving compliance. Ley and Morris (1984) examined the effect of written information about medication and found that it increased knowledge in 90 per cent of the studies, increased compliance in 60 per cent of the studies, and improved outcome in 57 per cent of the studies.

Behavioural methods.

Several behavioral methods are also effective in enhancing patients' motivation to adhere to their treatment regimens (DiMatteo & DiNicola, 1982; Epstein & Cluss, 1982). These methods include:

  1. Tailoring the regimen, in which activities in the treatment are designed to be compatible with the patient's habits and rituals. For example, taking a pill at home at breakfast or while preparing for bed is easier to do and remember for most people than taking it in the middle of the day.
  2. Providing prompts and reminders, which serve as cues to perform recommended activities. These cues can include reminder phone calls for appointments or notes posted at home that remind the client to exercise. Innovative drug packaging can also help— for instance, some drugs today come in dispensers with dated compartments or built-in reminder alarms.
  3. Self-monitoring, in which the patient keeps a written record of regimen activities, such as the foods eaten each day.
  4. Contingency contracting, whereby the practitioner and client negotiate a series of treatment activities and goals in writing and specify rewards the patient will receive for succeeding.

A major advantage of these methods is that the client can become actively involved in their design and execution (Turk & Meichenbaum, 1991). Further more, the patient can carry them out alone or with the aid of the practitioner, family, or friends.

Cited in Sarafino, 1994.