COMPLIANCE TO THERAPY

Defining the concept of compliance• Health care has financial ramifications

• Who pays for health care services?

• Who is responsible for providing efficient health care services (that is – benefits higher than costs)?

• The physician is required to recommendmedicationother medical and laboratory assessmentsdietlife style adjustmentscounseling on individual, family, social issues

• The patient is expected to follow these recommendations

Defining the concept of compliance• Research on compliance – a social psychology issue

• Compliance is defined as “the set of changes in an individual’s behavior, due to explicit group requests, demands or pressures elicited in order for the subject to follow the behaviors/ attitudes desired by the group

• Conformity involves implicit (not explicit) peer pressure, and individual beliefs similar to the group’s standpoint

• The factors involved in compliance are researched and identified

from a theoretical standpoint (what factors, to what extent, how?) from a practical standpoint (how to enhance compliance in a given

patient)

Defining the concept of compliance• Therapeutic compliance involvesBeliefs: similar/different to social beliefs, norms and demands

Behaviors: freely engaged in/taken on as “submission to peer pressure” • The patient’s beliefs about therapy differ from the

patient’s behaviors

• In therapeutic compliance, only behaviors count

• Therapeutic compliance is defined as the ratio recommendations followed completely/total of recommendations

• The factors involved in compliance are researched and identified

from a theoretical standpoint (what factors, to what extent, how?) from a practical standpoint (how to enhance compliance in a given patient)

Factors involved in compliance• Related to the therapeutic prescription: Some recommendations, by their nature, are difficult to followRestrictions for salt (heart conditions), sugar (diabetes), certain foods (allergies)Certain degrees of physical exercise

For some recommendations, the patient’s motivation is low and difficult to enhance

To quit smoking, to make drastic lifestyle changes (job, housing, daily routine…)

Task-related difficultiesComplex set of prescriptionsPrescriptions that cause discomfort or distress

Previous failure in following the recommended prescriptionIf the patient has already tried something and failed, he will be reluctant to trying

it again, so an assessment on previous treatments and their effectiveness is needed

Factors involved in compliance• Related to the prescribing physician: The doctor as a person with social, job-related prestige

The doctor as representative of social powersSocially powerful persons have better chance to elicit behavioral change in others

The doctor represents 5 types of social power: legitimated (i.e. social status), expert (training), informational, punitive, rewarding power

The doctor as coach, tutor, teacher, counselor Patience, tact, order, clarity and precision in verbal expression

Clear written instructions, informed consent

Communication suited to fit patient’s needs

The communication skillsAuthority is needed but an excess of it alienates the patient

Closeness is needed but if in excess, the patient may act familiar and ignore prescriptions

Distance - in some cases patients may think that the doctor is cold, insensitive

Factors involved in compliance

• Related to the patient (cognitive, moral, emotional): The patient’s level of understandingIf low, compliance will decrease

The patient’s personalityConformist and optimistic patients have higher levels of compliance

Avoidant, anxious, obsessive, impulsive, stubborn patient: problems in compliance

Previous misconceptions and misrepresentations on illness Negative impact on compliance

Deliberate non-compliancePatient who does not trust the doctor and dismisses the relationship

Patients who simulate an illness

Patients who request help but do not take on their responsibilities as patients

Factors involved in compliance• Related to the illness: The degree of severityTreatment for less severe illnesses is not taken as seriously

Acute versus chronic illnessMild acute illness – low compliance

Severe acute illness – high compliance (to get well and symptom-free quickly)

Chronic illness: mild symptoms=low compliance

Chronic illness with periods of severe acute symptoms=high compliance

Impact of illness on patient’s activities Impact of illness on the ability to eat, sleep

Impact on bladder or bowel functioning, on sex life…

Esthetic impact

Social impact (sexually transmitted diseases)

Patients with a special social status that involves many social, familial, job-related responsibilities

Factors involved in compliance• Related to social context: The power of group thinkingThe person seeks the group, for support

Peer pressure – the person adopts the ideas of the group

The person suppresses his doubts and fears concerning the ideas of the group

The person rationalizes or neglects information that contradict the group thinking

Intervention of family, colleagues, other patientsFamily support and active intervention increases compliance

Colleagues and job environment may decrease compliance if

- the patient feels that compliance to treatment/ the illness per se can cause him to lose the job

- the job/ colleagues make certain recommendations difficult to follow (stressful job, exposure to toxic substances, lifestyle changes impossible due to job requirements)

Other patients, met in the hospital

- they have specific information on the illness, treatments, medical team

- their influence and credibility is higher than the physician’s, because they have the same standpoint as the patient

How to assess compliance

• Questionnaires for specific conditions – patient self-assessment: compliance is overrated (50%, compared to actual compliance, which is never higher than 30%!!!! )

• Structured Interviews – the doctor asks a specific set of questions

• Patient notebooks – written accounts of dates, medication, results of assessments, side effects…

• Blood and urine levels of medication/ derivatives

• Counting the doses

How to increase compliance• Patient education, training, coaching

• Simplification of prescriptionsClear, simple, concise, precise prescriptions, demonstrations of therapeutic

methods

Realistic prescription (do not recommend what you expect not to be followed)

Informing the patient on expected side-effects

• Monitoring the treatment and evolution of illnessCharts, files

Regular check-ups

• Self-generated care and self-managementEncourage the patient to seek information, to make decisions

Family involvement in rewarding/ sanctioning the patient

Support groups

Ramecker’s decision making scheme

• Objectives and priorities of the treatment

• Decision: which of these are attainable

• Choices: lifestyle and behavior adjustments

• Constant adjustment of lifestyle and behavior to new requirements

• Final assessment: are the objectives and priorities met?