the compliance following medical advice

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The Compliance Following Medical Advice Amna Ahmad 4426 Aamna Haneef 4427 Ayesha Riaz 4433 Hira Nadeem 4438 Maliha Junaid 4441 Wuzna Harooon 4477 (Session: 2008 2012) Health Psychology Instructor’s Name: Mrs. Amna Khhawar Date of Submission: June 15 th , 2012 Department of Psychology Lahore College for Women University

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Page 1: The Compliance Following Medical Advice

“The Compl iance Fol lowing Medica l Advice ”

Amna Ahmad 4426

Aamna Haneef 4427

Ayesha Riaz 4433

Hira Nadeem 4438

Maliha Junaid 4441

Wuzna Harooon 4477

(Session: 2008 – 2012)

Health Psychology

Instructor’s Name:

Mrs. Amna Khhawar

Date of Submission: June 15th, 2012

Department of Psychology

L a h o r e C o l l e g e f o r W o m e n U n i v e r s i t y

Page 2: The Compliance Following Medical Advice

CONTENTS

1. Compliance: An Introduction…………..…………………………………………………1

2. Predicting Patient Compliance ……………………………………………………………8

3. Factors Affecting Adherence…………………………………………………………….12

4. The Role of Knowledge in Health Professional-Patient Communication……………….23

5. Improving Adherence……………………………………………………………………28

References………………………………………………………………………………..32

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Compliance Following Medical AdviceCompliance: An Introduction

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COMPLIANCE: AN INTRODUCTION

For medical advice to benefit patient’s health, two requirements must be met.

First, the advice must be valid

Second, the patient must follow this good advice

Both conditions are essential. Ill-founded advice that patients strictly follow may produce

new health problems that lead to disastrous outcomes for the compliant patients. On the other

hand, excellent advice is essentially worthless if patients do not follow it (Brannon & Feist,

2010).

Compliance:

The term compliance refers to “the extent to which the patient’s behavior (in

terms of taking medications, following diets, or executing other lifestyles

changes) coincides with medical or health instructions or prescriptions” (Carroll,

1992; Haynes 1979).

Compliance is regarded as important primarily because following the recommendations

of health professionals is considered essential to patient recovery (Ogden, 2010). However,

Harvey (1988) has pointed out that there are considerable problems with the term compliance.

The idea of physician authority and dominance and patient passivity and subservience is implicit

in the concept of compliance. Trostle (1988), in a well argued analysis, proposed that compliance

is in fact an ideology, derived from presumptions about the proper relationships between

physicians and other health professionals on one hand, and the clients or patients on the other.

From this perspective, compliance can be regarded as a generally unhelpful concept, save in

reinforcing the authority and power of physician and other health care professionals (Carroll,

1992).

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Compliance Following Medical AdviceCompliance: An Introduction

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The Concept of Adherence

Traditionally, people in the medical profession have used the term compliance to refer

patent’s behaviors that conform to physicians’ orders (Janet, 2001). But because of the term

implies reluctant obedience, many health psychologists and some physicians advocate the use of

other words, especially adherence.

“Adherence refers to a person’s ability and willingness to follow recommended

health practices” (Brannon & Feist, 2010).

Brain Haynes (1979) defines adherence as the extent to which a person’s behavior

(in terms of taking medicines, follow diets, or executing lifestyle changes)

coincides with medical or heath advice.

The term compliance and adherence are the most frequently used terms and these two are

sometimes used interchangeably.

Patients’ Non-Compliance and Compliance:

Compliance is the patient following the advice given by the doctor. Failure to follow such

advice is referred to as non-compliance (Broome, 1995). Non-compliance is not confined to

patients. Health care professionals also show high levels of non-compliance with rules for

optimal patient care (Ley, 1988).

Patients’ non-compliance with advice has been defined in a variety of ways. Ley (1988)

defines non-compliance for medication uptake as:

Not taking enough medicine;

Taking too much medicine;

Not observing the correct interval between doses;

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Compliance Following Medical AdviceCompliance: An Introduction

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Not making the correct duration of treatment; and

Taking additional non-prescribed medications

Two meta-analyses of treatment studies (DiMatteo, Giordani, Lepper & Croghan, 2002)

indicated large differences in the medical outcomes of adherent versus non-adherent patients.

These analyses showed that adherence can make a big difference in improvement (Brannon &

Feist, 2010).

Biological, psychological and sociocultural factors contribute to failures in adherence.

For example, after seeing a physician about an illness or injury, many people never get their

prescription filled (Snooks, 2009).

One of the biological determinants is fear that the medicine will cause

stomachaches.

A psychological reason might be resistance to the idea that they actually need to

take a medicine; and

Sociocultural reason may include economic concerns about the cost of medicine

or the time it will take to get the prescription filled.

Assessing Adherence

Measuring adherence is a complicated process in medicine and health psychology. All

techniques for measuring adherence have advantages and disadvantages. Medical practitioners

tend to over-estimate patient adherence to their recommendations. Many physicians simply

assume patients will follow their instructions. When they do not hear from the patient they

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Compliance Following Medical AdviceCompliance: An Introduction

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assume that their treatment recommendation was followed and was effective. There are many

ways through which adherence can be assessed (Snooks, 2009). These are as follows:

Measurement of Medication:

Measuring the amount of remaining medication is one way to monitor patient

cooperation. Counting remaining pills and weighing liquid medications left in the

bottles are used when studying the effectiveness of drug. In hospitals, people who

distribute medicines stay at the bedside until the patient swallow the medication;

however, there is less control in home situations.

Other techniques are pharmacy database review, computer-based monitoring,

and home nursing visits to ensure medication is taken and bandages are changed.

Biological and Chemical Monitoring:

Measurement of adherence may include assessing the effects of the

recommendation process or medication to be sure that the suggestions were followed.

Some examples are weighing weight loss or gain, taking blood pressure and heart

rate, and analyses of blood and body wastes. Some smoking cessation programs

monitor adherence by analyzing exhaled breath. Repeated assessment is difficult if

patients refuse to keep monitoring appointment.

Patient Self-Report:

It may seem straightforward to ask patients or participants if they followed

recommendations, but many times self-report are inaccurate. For example, many

weight loss programs require patients to write down everything they eat each week.

People are embarrassed when they eat the entire package of cookies, so they simply

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Compliance Following Medical AdviceCompliance: An Introduction

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omit writing about it. The same behavior occurs with regard to reporting exercise

adherence, because people want to please their trainers or coaches.

In the case of asthma attacks and chest pain, patients are more likely to use

medications, but may not remember how many times the attack or pain occurred.

Electronic Monitoring Devices:

One of the newest ways of measuring adherence is computer based

monitoring and telehealth. Web-based interventions are assessable, low in cost,

standardized, personalized, private, continent and may produce more accurate

reporting of behaviors.

Treatment outcomes might be a way to assess nonadherence, but there is little evidence

of a clear relationship between the extent of adherence and health outcomes. In short, many

factors obscure the relationship between adherence and recovery (Taylor, 2006).

Rates of Adherence in Medical Treatment

It is important for heath specialists to know the rates of patient adherence in order to

evaluate the effectiveness of counseling sessions, health-promotion programs, medical advice or

prescribed medications (Snooks, 2009). Adherence is difficult to measure but clinical studies

give some indication.

Estimates of non-adherence vary from a low of 15% to a staggering high of 93%.

On average, non-adherence is about 26% (DiMatteo, Giordani, Lepper &

Croghan, 2002).

Between 50% and 65% of out-patients do not adhere to their medication

regimens (Schuab, Steiner & Vetter, 1993)

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Many smokers relapse in the first 3 months after quitting.

In alcohol addictions, relapse often occurs during the first two years (Snooks,

2009)

For short-term antibiotics regimens, it is estimated that at least one-third of all

patients fail to comply adequately (Rapoff & Christophersen, 1982)

Between 50 to 60% of patients do not keep appointments for modifying

preventive health behaviors (DiMatteo & DiNicola, 1982).

As many as 80% of the patients drop out of lifestyle change program designed to

treat smoking or obesity (Dunbar & Agras, 1980).

More than 80% of the patients who receive behavioral change recommendations

from their doctors such as stopping smoking or following a restrictive diet fail to

follow these recommendations (Taylor, 2006).

In a study of children treated for the ear infection, it was estimated that only 5%

of the parents fully adhered to the medication regimen (Matter, Markello, &

Yaffe, 1975).

Heart patients, who should be motivated to adhere, such as patients in cardiac

rehabilitation, show an adherence rate of only 66 to 75% (Center for the

Advancement of Health, 2003).

Of 750 million new prescriptions written each year, approximately 520 million

are responded to with partial or total non-adherence (Buckalew & Sallis, 1986).

Adherence is typically so poor that researchers believe that the benefits of many

medications cannot be realized at the current level of adherence that the patients achieve

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(Haynes, McKibbon & Kanani, 1996). Researchers have found that adherence is highest in HIV

disease, arthritis, gastrointestinal disorders, and cancer and lowest amount patients with

pulmonary disease, diabetes and sleep disorders (DiMatteo et al., 2002).

Health Belief Model

Health Belief Model designed by Hochbaum (1958) was used to help researchers

investigate the psychology behind adherence to medical advice in today's society. This model

was used to explain the failure of people to participate in preventive health campaigns. The four

components that make up this model includes

1) the perceive threat of illness,

2) the benefits and barriers,

3) the action that should be taken and

4) the socio-demographic variables

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Compliance Following Medical AdvicePredicting Patients Compliance

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PREDICTING PATIENTS COMPLIANCE

Ley developed the cognitive hypothesis model of compliance. This claimed that

compliance can b predicted by a combination of patient satisfaction with the process of the

consultation, understanding of the information given and recall of this information.

Ley’s Model of Compliance

I. PATIENT SATISFACTION

Ley (1988) examined the extent of patient satisfaction with the consultation. He reviewed

21 studies of hospital patients and found that 41% of patients were dissatisfied with their

treatment and 28% of general practice patients were dissatisfied. Studies by Haynes et al.

(1979) and Ley (1988) found that levels of patient satisfaction stem from various

components of the consultation, in particular

1) The affective aspects (e.g. emotional support and understanding)

2) The behavioral aspects (e.g. prescribing, adequate explanation)

UNDERSTANDING

MEMORY

SATISFACTION COMPLIANCE

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3) The competence (e.g. appropriateness of referral, diagnosis) of the health

professional.

Ley also reported that satisfaction is determined by the content of the consultation and

that patients want to know as much information as possible, even if this is bad news. For

example, in studies looking at cancer diagnosis, patients showed improved satisfaction if they

were given a diagnosis of cancer rather than if they were protected from this information.

Berry et al. (2003) explored the impact of making information more personal to the

patient on satisfaction. Participants were asked to read some information about medication and

then to rate their satisfaction. Some given personalized information, such as ‘If you take this

medicine, there is a substantial chance of you getting one or more of its side effect’, whereas

some were given non-personalized information, such as ‘A substantial proportion of the people

who take this medication get one or more side effects’. The results showed that a more

personalized style was related to greater satisfaction, lower ratings of the risks of side effects

and lower ratings of the risk to health.

However, even though there are problems with patients satisfaction, some studies

suggests that aspects of patient satisfaction may correlate with compliance with advice given

during the consultation.

II. PATIENT UNDERSTANDING

Patients’ understanding of what they are told has been assessed in a number of ways,

including test of understanding of medical vocabulary; tests of knowledge of illnesses; patient’s

own reports about their understanding; clinicians’ interview judgments of patients’

understanding; and quasi behavioral tests.

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Boyle examined patients’ perceptions of the location of organs and found that only 42%

correctly located heart, 20% located the stomach and 49% located the liver. This suggests that

understanding of the content of the consultation may be low.

Patients also have error in their understanding of illness. Studies reviewed by Ley who

reported that the percentages of the patients judged by experts not to have adequate

understanding of their treatment regimen ranged from 5% to 69%.

If the doctor gives advice to the patient or suggests that they follow a particular treatment

program and the patient does not understand the cause of their illness, the correct location of the

relevant organ or the process involved in the treatment, then this lack of understanding is likely

to affect their compliance with this advice.

III. PATIENT RECALL

Studies of what patients remember of what they are told have been conducted in a variety

of hospital and general practice settings. The material involved has consisted to the clinician’s

conclusions about the illness, its treatment, investigation and prognosis, and advice to the

patient, or some subset of this material, or informed consent information.

Bain (1977) examine the recall from a sample of patients who had attended a GP

consultation and found that 37% could not recall the name of the drug, 23% could not recall the

frequency of the dose and 25% could not the duration of the treatment. A further study by

Crichton et al. (1978) found that 22% of the patients had forgotten the treatment regime

recommended by the doctors.

In meta-analysis of the research into recall of consultation information, Ley (1981, 1989)

found that recall is influenced by multitude of factors. For example, Ley argued that anxiety,

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medical knowledge, intellectual level, the importance of the statement, primacy effect and the

number of the statements increase recall. However, he concludes that recall is not influenced by

the age of the patient, which is contrary to some predictions of the effect of ageing on memory

and myths of ageing process. Recalling information after the consultation may be related to

compliance.

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Compliance Following Medical AdviceFactors Affecting Adherence

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FACTORS AFFECTING ADHERENCE

The possible predictors that affect the

adherence can be divided into five major groups

Severity of disease,

Treatment characteristics

Personal characteristics

Cultural norms and

Characteristics of relationship between health

care provider and the patient

SEVERITY OF DISEASE

Common wisdom suggest that people with severe, potentially crippling or life-

threatening illnesses will be highly motivated to adhere to regimens that protect them against

such outcomes. However, little evidence supports this reasonable hypothesis. In general, people

with a serious disease are no more likely than people with a less serious problem to seek medical

treatment. Indeed, people sometimes seek health care not because they believe they had a serious

medical problem but because of appearance or inconvenience. A study reported that pain

associated with illness not only pushes people toward medical care but also increases their level

of adherence.

A comprehensive review found that disease severity was not significantly related to

compliance. However, a meta-analysis showed that patient’s perception of the severity of the

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disease was strongly related to compliance. That is, the objective severity of a disease is less

closely related to adherence to medical recommendations concerning treatment or prevention

than the threat that people experience from a disease.

TREATMENT CHARACTERISTICS

Characteristics of treatment present potential problems for adherence. These

characteristics are:

Side effects of medication and

The complexity of treatment

Side effects of Medication

Early research found little evidence to suggest that unpleasant side effects are a

major reason for discontinuing a drug or dropping out of a treatment program.

However, a more recent research with the complex regimen of drugs for HIV

indicated that, especially among younger patients, those who experience severe

side effects are less likely to take their medications than those with minor side

effects.

Complexity of the Treatment

In general, the greater the number of doses or variety of medications people must

take, the greater is the likelihood that they will not take pills in the prescribed

manner. For, example, people who need to take one pill per day comply fairly

well (as high as 90%), and increasing the dosage to two per day produces little

decrease (Claxton, Cramer, & Pierce, 2001). When people must take four doses of

medication a day, however, adherence plummets to below 40%. The reason seems

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to be related to fitting medications into daily routines. Schedules calling for

medication to be taken four or more times a day create difficulties and lower

compliance rates.

In summary, the more complex the treatment, the lower is the rate of compliance. Philip

Ley concluded that, “the simpler the treatment schedule, and the shorter its duration, the greater

is compliance”.

PERSONAL FACTORS

Researchers have investigated that many personal and demographic factors related to

compliance. In general, the factors such as age and gender show some relationship to adherence,

but any of these factors alone is too small to be a good predictor of who will adhere and who will

not (DiMattco, 2004b). Personality was one of the first factors to be considered in relation to

compliance, and other personal factors such as emotional factors and personal beliefs have

appeared as contributors to adherence.

Age

Although age is not a major determinant of adherence, the relationship between

the two factors is not a simple one. Indeed, assessing adherence among children is

a difficult research endeavor in which the person whose adherence is important is

actually the parent and not the child. As children grow into adolescents, they

become more responsible for adhering to medical advices and remains till

adulthood. However, older people may face situations that make compliance

difficult, such as memory problems, poor health and regimens. These varying life

situations suggest a complex relationship between age and adherence. One study

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found a rounded relationship between age and compliance with colorectal cancer

screening. That is, those who complied best were around 70 years old, with older

and younger participants doing worse. Those who are 70 years old may not be the

best at adhering to all medical advice, but this result suggests that both older and

younger adults, plus children and adolescents, experience more problems with

adherence.

Even with caregivers to assist them, children with asthma, diabetes and

HIV infection often fail to adhere to their medical regimens. As they grow into

adolescence and exert more control over their own health care, adherence

problems become even more prominent.

Gender

With regard to gender, researchers have found few differences in the

overall adherence rates. The female sex was statistically associated with greater

non-adherence than males (Bonolo, et al., 2005). However, Wools-Kaloustian, et

al. 2006 found that, among other things, males were significantly more likely to

be lost to follow up than females. Despite all this, males were more likely to

admit to being more adherent to medical advice than females (Uzuchukwu et al,

2009).

Marriage

Unmarried respondents were less likely to report adherence to medical

advice. (Bonolo et al, 2005; Uzuchukwu et al, 2009).

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Education

Lower education is a predictor of poor adherence (Golin et al, 2002;

Karcher et al, 2007). To be more specific, Bonolo et al (2005) found out that non-

adherence was statistically associated with lower schooling (less than five years).

In a cross sectional study to determine the adherence to medical advice and its

determinants in India, Sarna, Pujari, et al (2008) showed that less than university

education was associated with lower adherence (that is less than 90%). Besides,

Uzuchukwu et al (2009) also reported that those without formal education were

less likely to report adherence.

Race

Race or ethnicity plays an important role in adherence. In a study

conducted by (Kleeberger et al, 2001) found out that African American race led to

poor adherence. As this study was conducted in the United States of America, this

kind of generalization can only be made to that population. Golin, et al., (2002)

did not support this finding.

Income and Employment

In the USA, income of less than 50,000 per annum, led to poor adherence

(Kleeberger et al, 2001). It is however important to note that 99% of people in

South Africa earn less than this. Golin, et al., (2002) support this notion when

they concluded that lower income was a predictor of poor adherence. This could

be an occurrence in the Bapong area as it is rural and most of the people are

unemployed or work as casual workers in the mines and therefore have a low

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income. Moreover, Sarna et al (2008) showed that, being unemployed was

associated with lower adherence (that is less than 90%).

Social support

There is a considerable amount of literature focusing on the association

of social isolation or social support with treatment adherence. As the amount and

type of treatment support will vary according to the treatment setting, the needs of

each individual also vary. The financial and practical barriers to

adherence include needing money for transport to the clinic, food, and sometimes

choosing between medicine or food for both the patient and their family.

A qualitative study has found that although participants valued social

support, especially in overcoming side-effects and the difficulties of taking the

drugs, those who provided support can both assuage and create problems. In

particular, many participants reported feeling under intense pressure from peers,

family and medical providers to take therapy, resulting in a fear of failing to meet

expectations and an unwillingness to be open about problems that were

encountered.

CULTURAL NORMS

Cultural beliefs and norms have a powerful effect not only on rates of compliance but

even on what constitutes compliance. For example, if one’s family or tribal traditions include

strong beliefs in the efficacy of tribal healers, it seems reasonable that the individual’s

compliance with modern medical recommendations might be low. A study of diabetic and

hypersensitive patients in Zimbabwe found a large number of people who were not adhering to

their recommended therapies. Many of the patients believed in traditional healers and had little

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faith in Western medical procedures. Thus, the extent to which people accept a medical practice

has a large impact on adherence to that practice, resulting in poorer adherence for individuals

who are less accultered to western medicine, such as immigrants or people who retain string tries

to another culture.

Failure to comply with Western Technological Medicine does not necessarily indicate a

failure to do with some other medical traditions. People who maintain a cultural tradition may

also retain its healers. People who accept a different healing tradition should not necessarily be

considered non adherent when their illness cause for a complex by medical regimen.

Cultural beliefs can also increase adherence, for example, older Japanese patients are typically

more adherent than similar patients are typically more adherent than similar patients from the US

or Europe. The Japanese health care system provides care for all citizens through a variety of

services, which creates trust in health care system. This trust extends to physicians; Japanese

patients accept their physician’s authority, preferring to allow physicians to make health care

decisions rather than making those decisions themselves. Consistent with this attitude, patients

tend to respect the advice they receive from physicians and to follow their orders successfully.

Culture and ethnicity also influence adherence through the treatment that people from

different cultures and ethnic groups receive when seeking medical care. Physicians and other

health care providers are influenced by their patients’ ethnic background and socioeconomic

status, and this influence related to patient’s compliance. Physicians tend to have stereotypical

and negative attitudes toward African American and low and middle income patients, including

pessimists beliefs about their rates of adherence. Perceived discrimination and disrespect

appeared as significant factors in a study on ethnic differences in following physicians’

recommendations and keeping appointments.

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These findings have important implications for physicians and other health care providers

whose clientele consists largely of people from different cultural backgrounds. In addition, these

findings highlight the importance of interactions between patient and practitioner in adhering to

medical advice.

PRACTITIONER-PATIENT INTERACTION

In addition to looking at disease characteristics and personal factors, researchers have

studied patient-practitioner interaction and its relation to adherence and non-adherence.

Practitioners who are successful in forming a working alliance with their patients are more likely

to have patients who are satisfied and who follow their recommendations. Important factors in

building successful practitioner-patient alliances include verbal communication and the

practitioner personal characteristics.

Verbal Communication

Perhaps the most crucial factor in patient non-compliance is poor verbal

communication between the practitioner and the patient. When patients believe that

physician understands their reasons for seeking treatment and that both agree about

treatment, adherence increases, but problem in communication present barriers to this

understandings.

1. Miscommunication can start when physicians ask patients to report on their

symptoms and fail to listen to patient’s concerns, interrupting their stories within

seconds. However, patients may misinterpret the physician’s behavior as a lack of

personal concern for the patient or as overlooking what patient concerns

important symptoms.

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2. After practitioners have made diagnosis, they typically tell patients about that

diagnosis. If the diagnosis is minor, patients may be relieved and not highly

motivated to adhere to any instructions that may follow.

3. If the verdict is serious, patients may become anxious or frightened, and these

findings may then interfere with their concentration or subsequent medical advice.

4. When patient fail to receive information that they have requested, they feel less

satisfied with their physician and are less likely to comply with the advice they

receive.

5. For a variety of reasons, physicians and patients do not speak the same language.

Physicians operate in similar territory, they know the subject matter, comfortable

with the surroundings and relaxed with the procedures that have become routine

for them. Whereas, the patients may be unfamiliar with the medical terminology,

distracted by the strange environment, and distressed by anxiety or pain.

In some cases, practitioners and patients do not speak the same language-literally.

Difference in native language present a major barrier in communication).

Even with interpreters, substantial miscommunication may occur, as a result

patient either fail to understand or to remember significant portions of the

information their doctors give them, with decreasing compliance.

Practitioner’s Personal Characteristics

A second aspect of the practitioner-patient interaction is the perceived personal

characteristics of the physician.

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1. As might expected, patient’s compliance improves as confidence in their

physician’s technical ability increases, but patients have difficulty assessing

technical competence and tent to assume that their physicians are competent.

2. In addition, several physicians’ personality variables – as perceived by the patient

– are related to compliance. Early research showed that people were more likely

to follow advice of the doctors they saw as warm, caring, friendly and interested

in the welfare of the patients.

3. Alternatively, when patients believe that physicians look down on them or treat

them with disrespect, patients are less likely to followphysicians advise or keep

medical advice.

4. Physicians’ personal characteristics are important to patients; patients appreciate

physicians who are confident, empathetic, humane, personal, forthright and

respectful.

5. Physician’s gender may also play a role in the exchange of information between

doctor and patient. Female physicians have an advantage in establishing the type

of relationship that lead to higher adherence because they tend to spend more time

with patients, make more partnership statements, engage in more patient-centered

talk and ask more questions than do male physicians.

Interaction of Factors

Researchers have identified dozens of factors, each of which shows some

relation to adherence. However many of these factors account for a very small amount

of the variation in adhering to medical advice.Patients’ beliefs about the disease are

related to compliance, but those beliefs are affected by interactions with physicians,

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another factor that has been identified as influential for adherence. Thus, the factors

are not independent. Many of the factors identified as being related to adherence

overlap with and influence other factors in complex ways. Therefore, both researchers

and practitioners will benefit from developing an appreciation for all and

understanding of the interaction among the many factors that affect adherence. This

understanding will help in the development of interventions to improve adherence.

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Compliance Following Medical AdviceThe Role of Knowledge in Health Professional-Patient Communication

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THE ROLE OF KNOWLEDGE IN HEALTH

PROFESSIONAL-PATIENT COMMUNICATION

Ley’s approach to health professional-patient communication can be understood within

the framework of an educational model involving the transfer of medical knowledge from expert

to layperson (Marteau & Johnson, 1990). This traditional approach has motivated research into

health professional’s medical knowledge, which is seen as a product of their training and

education.

Boyle (1970), although emphasizing patient’s knowledge provided some insights into

doctor’s knowledge of the location of organs and the causes of a variety of illnesses. The results

showed that although the doctor’s knowledge was superior to that of the patients, some doctors

wrongly located organs such as the heart and wrongly defined problems such as “constipation”

and “diarrhea. It has also been found that health professionals show inaccurate knowledge about

diabetes and asthma.

Murray et al, (1993) examined the dietary knowledge of primary care professionals in

Scotland. GPs, community nurses and practice nurses completed a questionnaire

consisting of a series of commonly heard statements about diet and were asked to state

whether they agreed or disagreed with them. The authors concluded that primary health

care professionals show generally good dietary knowledge.

Problems with the traditional approach to health professional-patient communication:

Traditional models of the communication between health professionals and patients have

emphasized the transfer of knowledge from expert to layperson. Ley’s cognitive hypothesis

model of communication includes a role for the patient and emphasizes patient factors in the

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communication process as well as health professional factors. This approach has encouraged

research into the wider role of information in health and illness. However, there are several

problems with this educational approach, these are as follow:

It assumes that the communication from the health professional is from an expert whose

knowledge base is one of objective knowledge and does not involve the health beliefs of

that individual health professional.

Patient adherence is seen as positive and unproblematic.

Improved knowledge is predicted to improve the communication process.

It does not include a role for patient health beliefs.

THE ADHERENCE MODEL OF COMMUNICATION:

Stanton developed the model of adherence.

The model suggested that communication from the health professional results in

enhanced patient knowledge and patient satisfaction and an adherence to the

recommended medical regime.

It also suggested that patients’ beliefs are important and the model emphasized the

patient’s locus of control, perceived social support and the disruption of lifestyle involved

in adherence.

However this model of communication assumes that the health professionals’ information

is based on objective knowledge and is not influenced by their own health beliefs. Patients are

regarded as laypeople that have their own varying beliefs and perspectives that need to be dealt

with by the doctors and addressed in terms of the language and content of the communication.

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Leventhal and Camerson outlined four general theoretical perspectives on adherence. These are

as follow:

Biomedical perspective

Behavioral perspective

Communication perspective

Cognitive perspective

Biomedical Perspective:

The biomedical approach to adherence assumes that patients are more-or-less passive

followers of their doctor’s orders, further to a diagnosis and prescribed therapy. Technological

innovations (e.g. assessing levels of adherence using biochemical measures, developing new

devices to administer medications) have had this as their impetus. However, other important

factors, such as patient’s views about their symptoms or their medications have been largely

ignored.

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Behavioral Perspective:

Behavioral perspective emphasizes the importance of positive and negative

reinforcement as a mechanism for influencing behavior, and this has immediate relevance

for adherence. From a theoretical standpoint it would be possible to “control” the

behavior of patients, providers and health care systems if one could control the events

preceding and following a specific behavior. From a practical standpoint, behavioral

principles can be used to design interventions that have the potential to incrementally

shape behavior at each level of influence to address adherence problems.

Communication Perspective:

Communication perspectives that emerged in the 1970s encouraged health care

providers to try to improve their skills in communicating with their patients. This led to

emphasis being placed on the importance of developing rapport, educating patients,

employing good communication skills and stressing the desirability of a more equal

relationship between patient and health professional. Although this approach has been

shown to influence satisfaction with medical care, convincing data about its positive

effects on compliance are scarce. Adopting a warm and kind style of interaction with a

patient is necessary, but is insufficient in it to effect changes in the adherence behaviors

of patients.

Cognitive Perspective:

Cognitive variables and processes have been applied to adherence behavior.

Examples of these include the health belief model, social-cognitive theory, the theory

planned behavior and the protection-motivation theory. Although these approaches have

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directed attention to the ways in which patients conceptualize health threats and appraise

factors that may be barrier to, or facilitate, adherence they do not always address

behavioral coping skills well.

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IMPROVING ADHERENCE

It is helpful if people are convinced they are responsible for their health and for

maintaining a health-related behavior. Smoking cessation programs and taking insulin for

diabetes illustrated this phenomenon. It is beneficial to provide people with information about

the necessity for behavior change. For example, most people will not conform to a medical

recommendation just because a doctor said so, although parents of young children frequently use

this kind of reasoning to change their children’s behavior. People are more likely to adhere to

suggestions by a fitness or diet consultant when the reasoning behind a recommendation is

clearly stated.

Simplifying recommendations is usually beneficial. Ways to reduce barriers to a

behavior change are worth discussing to improve adherence. Cues to positive behaviors

are also helpful. For example, putting running shoes in plain sight and cookies out of

sight may encourage exercise and discourage snacking. Specially designed pill packages

and calendars increase adherence for taking medications.

Phone calls and postcards remind people of behavior modification classes and increase

attendance and adherence. Some fitness trainers charge the same fee even when

participants do not attend a workout session. Knowing this encourages participants to

make every session or call in advance to cancel. Tailoring a regimen to one’s lifestyle is

also effective.

In order to maximize the benefit of the medical treatment, both physician and patient

need to work together to achieve the common goal. Enlisting and encouraging family

members to be supportive is also very useful for improving compliance.

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ORAL COMMUNICATION:

One way of improving compliance is to improve communication in terms of the content

of an oral communication.

Primary effect- patients have a tendency to remember the first thing they are told

To simplify the information

To be specific

To follow up the consultation

WRITTEN INFORMATION:

Researches also looked at the use of written information in improving compliance. Ley

and Morris examined the effect of written information about medication and found that it

increased knowledge in 90 percent of the studies, increased compliance in 60 percent of the

studies and improved outcome in 57 percent of the studies.

Coping skills information is also helpful; it can educate the individual about possible

coping strategies.

GUIDELINES FOR IMPROVING ADHERENCE TO TREATMENT:

Non-adherence to treatment is a formidable medical problem, and many of the reasons

can be traced directly to poor communication between the provider and the patient. The

following are some guidelines that can help improve adherence.

Listen to the patient.

Ask the patient to repeat what has to be done.

Keep the prescription as simple as possible.

Give clear instructions on the exact treatment regimen, preferably in writing.

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Make use of special reminder pill containers and calendars.

Call the patient if an appointment is missed.

Prescribe a self-care regimen in concert with the patient’s daily schedule.

Emphasize at each visit the importance of adherence.

Gear the frequency of visits to adherence needs.

Acknowledge at each visit the patient’s effort to adhere.

Involve the patient’s spouse or other partner.

Whenever possible, provide patients with instructions and advice at the start of the

information to be presented.

When providing patients with instructions and advice, stress how important they are.

Use short words and short sentences.

Use explicit categories where possible. (For example, divide information clearly into

categories of etiology, treatment, or prognosis.)

Repeat things, where feasible.

When giving advice, make it as specific, detailed, and concrete as merely to possible.

Find out what the patient’s worries are. Do not confine yourself merely to gathering

objective medical information.

Find out the patient’s expectations are. If they cannot be met, explain why.

Provide information about the diagnosis and the cause of the illness.

Adopt a friendly rather than a businesslike attitude.

Avoid medical jargon.

Spend some time in conversation about nonmedical topics.

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Conclusion:

Adherence refers to the practice of following health-related recommendations and

maintaining behavior changes. It is difficult to directly measure adherence. Research reports

suggest adherence rates are very low for most health-related behaviors, including taking

prescribed medications. Health-promotion interventions should always include plans for

promoting adherence.

Traditional educational models of doctor-patient communication emphasized patient

factors and considered non-compliance to be result of patient variability. Adherence to medical

recommendations continues to be a major concern for patients with long-term medical

conditions. The health care professional can enhance adherence by clarifying and tailoring the

regimen, identifying behavioral cues.

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References |32

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