Вы находитесь на странице: 1из 37

The Compliance Following Medical Advice

Amna Ahmad Aamna Haneef Ayesha Riaz Hira Nadeem Maliha Junaid 4426 4427 4433 4438 4441

Wuzna Harooon 4477 (Session: 2008 2012)

Health Psychology Instructors Name: Mrs. Amna Khhawar

Date of Submission: June 15th, 2012 Department of Psychology

Lahore College for Women University


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 Adherence28


Compliance Following Medical Advice 1 Compliance: An Introduction

For medical advice to benefit patients 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 patients 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 Advice 2 Compliance: An Introduction

The Concept of Adherence

Traditionally, people in the medical profession have used the term compliance to refer patents 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 persons ability and willingness to follow recommended

health practices (Brannon & Feist, 2010).

Brain Haynes (1979) defines adherence as the extent to which a persons 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 Advice 3 Compliance: An Introduction

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 Advice 4 Compliance: An Introduction

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 Advice 5 Compliance: An Introduction

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 Advice 6 Compliance: An Introduction

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 Advice 7 Compliance: An Introduction

(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 Advice 8 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.





Leys Model of Compliance


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)

Compliance Following Medical Advice 9 Predicting Patients Compliance

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.


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; patients own reports about their understanding; clinicians interview judgments of patients understanding; and quasi behavioral tests.

Compliance Following Medical Advice 10 Predicting Patients Compliance

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.


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 clinicians 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,

Compliance Following Medical Advice 11 Predicting Patients Compliance

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 Advice 12 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

Common wisdom suggest that people with severe, potentially crippling or lifethreatening 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 patients perception of the severity of the

Compliance Following Medical Advice 13 Factors Affecting Adherence

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 Advice 14 Factors Affecting Adherence

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

Compliance Following Medical Advice 15 Factors Affecting Adherence

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).

Compliance Following Medical Advice 16 Factors Affecting Adherence

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 nonadherence 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 Advice 17 Factors Affecting Adherence

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 beliefs and norms have a powerful effect not only on rates of compliance but even on what constitutes compliance. For example, if ones family or tribal traditions include strong beliefs in the efficacy of tribal healers, it seems reasonable that the individuals 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 Advice 18 Factors Affecting Adherence

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 physicians 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 patients 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.

Compliance Following Medical Advice 19 Factors Affecting Adherence

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.

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 patients concerns, interrupting their stories within seconds. However, patients may misinterpret the physicians behavior as a lack of personal concern for the patient or as overlooking what patient concerns important symptoms.

Compliance Following Medical Advice 20 Factors Affecting Adherence

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.

Practitioners Personal Characteristics A second aspect of the practitioner-patient interaction is the perceived personal characteristics of the physician.

Compliance Following Medical Advice 21 Factors Affecting Adherence

1. As might expected, patients compliance improves as confidence in their physicians 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. Physicians 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 Advice 22 Factors Affecting Adherence

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 Advice 23 The Role of Knowledge in Health Professional-Patient Communication


Leys 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 professionals medical knowledge, which is seen as a product of their training and education. Boyle (1970), although emphasizing patients knowledge provided some insights into doctors knowledge of the location of organs and the causes of a variety of illnesses. The results showed that although the doctors 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. Leys cognitive hypothesis model of communication includes a role for the patient and emphasizes patient factors in the

Compliance Following Medical Advice 24 The Role of Knowledge in Health Professional-Patient Communication

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 patients 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 Advice 25 The Role of Knowledge in Health Professional-Patient Communication

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 doctors 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 patients views about their symptoms or their medications have been largely ignored.

Compliance Following Medical Advice 26 The Role of Knowledge in Health Professional-Patient Communication

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 Advice 27 The Role of Knowledge in Health Professional-Patient Communication

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 Advice 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 childrens 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 ones 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 Advice 29 Improving Adherence

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.


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 Advice 30 Improving Adherence

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 patients daily schedule. Emphasize at each visit the importance of adherence. Gear the frequency of visits to adherence needs. Acknowledge at each visit the patients effort to adhere. Involve the patients 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 patients worries are. Do not confine yourself merely to gathering objective medical information. Find out the patients 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 Advice 31 Improving Adherence

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

Boyle.C.M. (1970). Differences between patients and doctors interpretations of common medical terms, British Medical Journal, 2: 286-9. In Ogden.J. (2007). Health psychology a textbook. (4thEd). Tata McGraw-Hill. Brannon, L. & Feist, J., (2010) Health Psychology: An Introduction to Behavior and Health (7th Ed). Wadsworth Cengage Learning In, Belmont USA Broome, A & Llewelyn, S.,(1995). Health Psychology Process and Application.(2nd Ed). Published by Chapman & Hall, London, U.K. Retrieved on June 13 2012 from URL: http://books.google.com.pk/books?id=3szcV3L4OBEC&pg=PA80&dq=compliance+follow ing+medical+advice+in+health+psychology&hl=en&sa=X&ei=bXWT9i3C8bwrQf3jIX9Dw&ved=0CG4Q6AEwCQ#v=onepage&q=compliance%20followi ng%20medical%20advice%20in%20health%20psychology&f=false Buckalew, L., & Sallis, R. (1986). Patient compliance and medication perception. Journal of Clinical Psychology, 42, 49-53. In Taylor, S. (2006) Heath Psychology, Tata McGraw Hill Edition Carroll, D. (1992) Heath Psychology: Stress, Behavior and Disease, the Falmer Press, Taylor & Francis Inc. Bristol USA DeMatteo, M. R., Giordani, P. J., Lepper, H. S., & Croghan, T. W. (2002). Patient adherence and medical treatment outcomes: A meta-analysis. Medical Care, 40(3), 200-209. Brannon, L. & Feist, J., (2010) Health Psychology: An Introduction to Behavior and Health (7th Ed). Wadsworth Cengage Learning In, Belmont USA. And in Taylor, S. (2006) Heath Psychology, Tata McGraw Hill Edition

References |33

DiMatteo, M. R., & DiNicola, D.D., (1982) Achieving Patient Compliance with medical regimens: A social psychological perspective. In Taylor, S. (2006) Heath Psychology, Tata McGraw Hill Edition Dunbar, J. M., & Agras, W. S. (1980) Compliance with Medical Instructions. In Taylor, S. (2006) Heath Psychology, Tata McGraw Hill Edition Haynes R.B., McKibbon, K. A., Kanani, R., (1996) Systematic review of randomized trials of interventions to assist patients to follow prescriptions for medications. Lancet: 348 (9024): 383-386. In Taylor, S. (2006) Heath Psychology, Tata McGraw Hill Edition. Haynes, R. B., (1979) Compliance in Health Care. Baltimore, MD: Johns Hopkins University Press. In Ogden, (2010) Heath Psychology: A Textbook, (4th Ed), Tata McGraw Hill Edition Hervey, P., (1988) Health psychology. Longman, New York. In Carroll, D. (1992) Heath Psychology: Stress, Behavior and Disease, the Falmer Press, Taylor & Francis Inc. Bristol USA. In Carroll, D. (1992) Heath Psychology: Stress, Behavior and Disease, the Falmer Press, Taylor & Francis Inc. Bristol USA Hochbaum, G. M. (1958) Public Participation in Medical Screening Program: a sociopsychological study. Public Health Service, publication, Washington DC. Ley, P. (1988) Communicating with Patients. London: Croom Helm. Ley outlines work on patient compliance and factors which are influential in determining compliance. In Broome, A., (editor), (1995) Heath Psychology: Processes and Application, Chapman & Hall, London

References |34

Marteau.T.M & Johnston.M. (1990). Health professionals: a source of variance in health outcomes, Psychology and Health, 5: 47-58. In Ogden.J. (2007). Health psychology a textbook. (4thEd). Tata McGraw-Hill. Matter, M. E., Markello, J., & Yaffe, S. J. (1995) Pharmaceutic Factors Affecting Pediatric Compliance, Pediatrics Vol 55:1 (101-108). In Taylor, S. (2006) Heath Psychology, Tata McGraw Hill Edition Ogden. J.,(2010). Health Psychology: A text book. (4th Ed). Tata McGraw Hill edition. Retrieved on June 13,2012 from URL: http://books.google.com.pk/books?id=7WbV6iRqrkC&pg=PA74&dq=compliance+following+medical+advice+in+health+psychology&hl=e n&sa=X&ei=bXWT9i3C8bwrQf3jIX9Dw&ved=0CFsQ6AEwBg#v=onepage&q=complian ce%20following%20medical%20advice%20in%20health%20psychology&f=false Rapoff, M.A. & Christophersen, E.R. (1982). Improving compliance in pediatric practice. Pediatric Clinics of North America, 29, 339 357. In Taylor, S. (2006) Heath Psychology, Tata McGraw Hill Edition Sabate.E, (2003). Adherence to long-term therapies evidence for action. World health organization. Schaub, A. F., Steiner A., & Vetter, W. (1993) Compliance to Treatment, Clinical and Experimental Hypertension, New York: 15(6): 1121-1130. In Snooks, M. K., (2009) Heath Psychology: Biological, Psychological and Sociocultural Perspective, Jones and Bartlett publishers LLC Snooks. M. K.,(2009). Health Psychology: Biological, Psychological, and Sociocultural Perspectives. Jones and Barlett publishers, LLC. Retrieved on June 13, 2012 from URL: http://books.google.com.pk/books?id=baPAscCphEYC&pg=PA74&dq=compliance+followi

References |35

ng+medical+advice+in+health+psychology&hl=en&sa=X&ei=bXWT9i3C8bwrQf3jIX9Dw&ved=0CFYQ6AEwBQ#v=onepage&q=compliance%20followi ng%20medical%20advice%20in%20health%20psychology&f=false Taylor. S.E., (2006). Health Psychology. (6th Ed). Tata McGraw Hill edition. Retrieved on June 13, 2012 From URL: http://books.google.com.pk/books?id=pTHZtfMFIPIC&pg=PA255&dq=compliance+follow ing+medical+advice+in+health+psychology&hl=en&sa=X&ei=bXWT9i3C8bwrQf3jIX9Dw&ved=0CGgQ6AEwCA#v=onepage&q=compliance%20followi ng%20medical%20advice%20in%20health%20psychology&f=false Trostle, J. A., (1988) Medical compliance as Ideology. Social Science and Medicine, 27(12), 1299-1308. In Carroll, D. (1992) Heath Psychology: Stress, Behavior and Disease, the Falmer Press, Taylor & Francis Inc. Bristol USA