the compliance following medical advice
TRANSCRIPT
“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
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
Compliance Following Medical AdviceCompliance: An Introduction
1
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).
Compliance Following Medical AdviceCompliance: An Introduction
2
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;
Compliance Following Medical AdviceCompliance: An Introduction
3
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
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
Compliance Following Medical AdviceCompliance: An Introduction
5
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)
Compliance Following Medical AdviceCompliance: An Introduction
6
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
Compliance Following Medical AdviceCompliance: An Introduction
7
(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
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
Compliance Following Medical AdvicePredicting Patients Compliance
9
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.
Compliance Following Medical AdvicePredicting Patients Compliance
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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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11
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.
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
Compliance Following Medical AdviceFactors Affecting Adherence
13
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
Compliance Following Medical AdviceFactors Affecting Adherence
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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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15
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
Compliance Following Medical AdviceFactors Affecting Adherence
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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
Compliance Following Medical AdviceFactors Affecting Adherence
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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.
Compliance Following Medical AdviceFactors Affecting Adherence
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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.
Compliance Following Medical AdviceFactors Affecting Adherence
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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,
Compliance Following Medical AdviceFactors Affecting Adherence
22
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.
Compliance Following Medical AdviceThe Role of Knowledge in Health Professional-Patient Communication
23
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
Compliance Following Medical AdviceThe Role of Knowledge in Health Professional-Patient Communication
24
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.
Compliance Following Medical AdviceThe Role of Knowledge in Health Professional-Patient Communication
25
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.
Compliance Following Medical AdviceThe Role of Knowledge in Health Professional-Patient Communication
26
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
Compliance Following Medical AdviceThe Role of Knowledge in Health Professional-Patient Communication
27
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.
Compliance Following Medical AdviceImproving Adherence
28
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.
Compliance Following Medical AdviceImproving Adherence
29
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.
Compliance Following Medical AdviceImproving Adherence
30
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.
Compliance Following Medical AdviceImproving Adherence
31
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.
References |32
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