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)

2 Comments:

Blogger Ade said...

Hi! Can you tell me where can I find DiMatteo and Nicola's 1982 study? Thank you!

12:38 PM  
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