Why patients do not adhere to

medical advice.

Health Psychology
Compliance
Adherence
Concordance
Degree to which the patient carries out the
behaviours the physician recommends (e.g.,
taking medication).
Extent of non-adherence problem
Difficulties with assessing it:
Many different kinds of medical advice to which
one could adhere
Can violate advice in many different ways
Difficult to know if patient complied (50/50 chance
that the physicians judgment of the patients
adherence is accurate).
Adherence
60% of patients may not be adhering to
long-term treatment regimen 1-2 years later
even in cardiac patients medication
adherence over time is poor (i.e., 40%
nonadherent 3 years later)
Good predictor of long-term adherence is
adherence at entry
Distribution of adherence is tri-modal
Distribution of Adherence
Adherent Partial Adherent Non-adherent
1/3
1/3
1/3
Measuring Adherence in Clinical
Practice
Physician impression overestimates patient-
adherence by about 50% (Caron, 1985).
Electronic monitors of pills taken are impractical
in routine clinical practice.
Bio-chemical measures also have limitations
Self-report methods are good at detecting those
who admit to adherence difficulties but will miss-
classify about 50% patients who deny problems
or who are unaware of a problem.
Forms of Non-Adherence
Forgetting a dose
Deliberately skipped doses
Occasional day or even week off therapy
Stopped therapy
Patients Reasons for Not
Adhering
Forgetfulness (e.g., restaurant, trip)
Financial (wait until pay day, take 1/2 dose to delay
renewing prescription)
Feeling sick
Feel well (rare reason)
Lazy about going to the drug store
Too busy - forget
Life events, stress (e.g., death in family)
Dont believe in the treatment
Confused about dosage
Rational Reasons for Non-
adherence
Have reason to believe the treatment isnt
working
Feel that side-effects are not worth the benefits
of treatment
Dont have enough money to pay for treatment
Want to see if the illness is still there when
they stop the treatment
Non-adherence: Characteristics
of the regimen
Complex regimens have low adherence
Adherence decreases with duration of the
regimen
Expense decreases adherence

Non-adherence: Cognitive-
Emotional Factors
Patients forget much of what the doctor tells
them
Instruction and advice are forgotten more readily
than other kinds of information
The more patient is told, the higher the
likelihood of forgetting more.
Patients remember what they are told first and
what they think is most important.
Non-adherence: Cognitive-
Emotional Factors
More intelligent patients do not remember more
than less intelligent patients
Older patients remember as much as younger
patients
Moderately anxious recall more than low or high
anxious patients
The more medical knowledge the patient has,
the more he/she will remember.
Non-Adherence: Psychosocial
Factors
Social support
Personality - Dispositional Attitudes
Affective State
Knowledge and attitudes
Non-Adherence:
Knowledge/Beliefs
Lack of knowledge
Denial or trivialization
Perceived invulnerability

Necessary but not sufficient
Non- Adherence - Behaviour

Early adherence, e.g., within first month of
initiating therapy is an excellent predictor of
later adherence, even 7 years later (Dunbar &
Knoke, 1986)
The more similar the predictor behaviour to
the predicted behaviour, the higher the
correlation.
Generally, little evidence for a health-oriented
behaviour pattern.
Whey dont people adhere?

Did not understand the treatment regime
(inadequate or non-existent instructions)
Forget
Side effects
Lack of commitment
Travel away from home
Depression
Feel better did not see need for completion
Why do people fail to take
medicines properly?
Non-adherence leads to
ineffective treatment
Additional health care expenditure
Anti-biotic resistance
How can services can help adherence?
Spend time explaining the importance of
adherence and help them to choose
strategies that can help them to adhere
More appropriate drug regimes (e.g.
shorter times for completion of treatment)
More acceptable presentation e.g. sugar
coated anti-malarials, syrups etc.
Suitable packaging blister packaging
lay-out
Instructions with the packaging - simple
words/pictures
Involve partners so they can remind their
partners

Medicine labelling/packaging

Used to explain
Dose, timing, side effects, things to avoid while taking
medicines

Communication depends on:
Size/clarity of letters
Language and complexity of words
Literacy of audience and familiarity with medical terms
Quality/comprehensibility of pictures and picture
symbols e.g. sun/moon for time of day
Increasing Patient Adherence
Use clear (jargon free) sentences
Repeat key information
Recruit sources of support
Tailoring the regimen
Providing prompts and reminders
Self-monitoring
Behavioural contracting
Integrate regimes into daily routines
Have a checklist for recording doses taken
Count out daily doses as week at a time
Use a pill box, alarm or daily planner

Strategies that people can use to
remember doses
Examples of methods methods
used to encourage adherance

Leaflets, instructions
Blister packaging
A programme in South
Africa used text
messaging to remind
people to take their
tuberculosis medicines
Visual aids like
calendars
Poster warning dangers
of combining drugs and
alcohol (Nicaragua)

Poster put up on the
walls of clinics in UK to
prevent unnecessary use
of antibiotics
Extent of problem

Taylor (1990) 93% of patients fail to adhere
to some aspect of their treatment.

Extent of problem

Sarafino(1994) People adhere to treatment
regimes reasonably closely 78% of the time.
Sarafino found the average adherence rates
for taking medicine to prevent illness is
60% for short and long term regimes.
Compliance to change one's diet or to give
up smoking is variable and low.
Extent of problem

Compliance with chemotherapy is very high
among adults with estimates of better than
90 percent of patients complying with the
treatment.

Extent of problem

Non compliance takes many forms. Some
patients do not keep appointments; others
do not follow advice.
Many patients fail to collect their
prescriptions, discontinue medication early,
fail to change their daily routine, and miss
follow-up appointments (Sackett and Hayes,
1976).

Kent and Dalgleish (1996)
Kent and Dalgleish (1996) describe a study
in which many parents of children who
were prescribed a ten-day course of
penicillin for a streptococcal infection did
not ensure that their children completed the
treatment.
The majority of the parents understood the
diagnosis, were familiar with the medicine
and knew how to obtain it.

Kent and Dalgleish (1996)
Despite the fact that the medication was
free, the doctors were aware of the study
and the families knew they would be
followed up, by day three of the treatment
41% of the children were still being given
the penicillin, and by day six only 29%
were being given it.
(Ley, 1997).
The costs associated with non-adherence
can be high.
The illness may be prolonged in the patient
and he or she may need extra visits to the
doctor.
These are not the only costs, however, as
the person may have a longer recovery
period, might need more time off work or
even require a stay in hospital.
(Ley, 1997).
Non-adherence may lead to as much as
10%20% of patients needing a second
prescription, 5%10% visiting their doctor
for a second time, the same number needing
extra days off work, and about 0.25 %1%
needing hospitalisation (Ley, 1997).

Methodological problem

Percentages are overestimated because
patients who tend to volunteer for these
studies would be more likely to be
compliant.

Methodological problem

Patients often lie about their level of
adherence, so as to present a good
impression of themselves.
It has been reported in the press that those
patients who smoke may be afforded a low
level of priority, when they are in need of a
transplant.
Patients might lie about their smoking, to
avoid such discrimination.

Why patients do and don't
adhere to advice

Patients are less likely to change habits than
heed medical advice to take medicine
(Haynes, 1976).

Why patients do and don't
adhere to advice

Patients who view their illness as severe are
more likely to comply (Becker &
Rosenstock, 1984).
Notice it is how the patient views the
seriousness of the illness, not what the
physician thinks!

Why patients do and don't
adhere to advice

Doctors tend to blame their patients for non-
adherence, attributing their behaviour to
characteristics of their patients (mental
capacity or personality traits) - Davis
(1966).

Why patients do and don't
adhere to advice

Research has shown that it is not the
patient's personality that predicts non-
adherence, but a combination of factors
arising out of the doctor - patient
relationship (e.g. Ley 1982).
Factors such as age and gender are
predictive of compliance, depending upon
what instructions are to be complied with.

Classic experiments - Milgram
(1963) and Asch (1955.


Milgram's experiment demonstrated that
ordinary people will obey authority figures,
to the extent that they would administer
potentially lethal 'electric shocks' to a mild-
mannered victim.
Asch's experiment demonstrated that
people will agree with others even though it
is obvious others are wrong.


(Haynes 1976).
If medication is prescribed over a long time,
it's more likely to be discontinued early
(Haynes 1976).

Patients Report % Compliant
Doctor businesslike 31
Doctor friendly but
not businesslike
46
High satisfaction with
consultation
53
Moderate satisfaction
with consultation
43
Moderate
dissatisfaction with
consultation
32
High dissatisfaction
with consultation
17
Types of request

requests for short-term compliance with
simple treatments
requests for positive additions to lifestyle
requests to stop certain behaviours
requests for long-term treatment regimes

Ley model of patient compliance (1989).
Patient satisfaction

Ley (1988) reviews 21 studies of hospital
patients and found that 28% of general
practice patients in the UK were dissatisfied
with the treatment they received.
Dissatisfaction amongst hospital patients
was even higher with 41 per cent
dissatisfied with their treatment.
Patient satisfaction

The dissatisfaction stemmed from affective
aspects of the consultation (e.g. lack of
emotional support and understanding),
behavioural aspects (e.g. prescribing,
adequate explanations) and competence
(e.g. appropriateness of the referral,
diagnosis).

Patient satisfaction

It was found that patients were "information
seekers" (i.e. wanted to know as much
information is possible about their
condition), rather than "information
blunters" (i.e. did not want to know the true
seriousness of their condition).
Patient satisfaction

Over 85% of cancer patients wanted all
information about diagnosis, treatment and
prognosis (the chances of treatment being
successful) (Reynolds et al., 1981).
Patient satisfaction

60 to 98% of terminally ill patients wanted
to know their bad news (Veatch, 1978).
Patient satisfaction

Older research had found that a small but
significant group did not want to be given
the truth for cancer and heart disease
(Kubler-Ross, 1969).
These findings could be due, in part, to the
attitudes that prevailed during the late
Sixties.
Research suggests that attitudes have
changed since then.
TESTING A THEORY -
PATIENT SATISFACTION
A study to examine the effects of
a general practitioner's consulting
style on patient satisfaction
(Savage and Armstrong 1990).

Methodology
Subjects
The study was undertaken in group
practices in an inner city area of London.
Four patients from each surgery for one
doctor, over four months were randomly
selected for the study.

Methodology
Patients were selected if they were aged 16-
75, did not have a life-threatening
condition, if they were not attending for
administrative/preventative reasons, and if
the GP involved considered that they would
not be upset by the project.


Methodology
Overall, 359 patient were invited to take
part in the study and a total of 200 patients
completed all assessments and were
included in the data analysis.


Design
The study involved a randomised controlled
design with two conditions: (1) sharing
consulting style and (2) directive consulting
style.
Patients were randomly allocated to one
condition and received a consultation with
the GP involving the appropriate consulting
style.

Procedure
A set of cards was designed to randomly
allocate each patient to a condition.
When a patient entered the consulting room
they were greeted and asked to describe
their problem.
When this was completed, the GP turned
over a card to determine the appropriate
style of consultation.

Procedure
Advice and treatment were then given by
the GP in that style.
For example, the doctor's judgement on the
consultation could have been either 'This is
a serious problem/I don't think this is a
serious problem' (a directive style) or 'Why
do you think this has happened?' (a sharing
style).

Procedure
For the diagnosis, the doctor could either
say 'You are suffering from. ..' (a directive
style) or 'What do you think is wrong?' (a
sharing style).
For the treatment advice the doctor could
either say 'It is essential that you take this
medicine' (a directive style) or 'What were
you hoping I would be able to do?' (a
sharing style).

Procedure
Each consultation was recorded and
assessed by an independent assessor to
check that the consulting style used was in
accordance with that selected.
Measures
All subjects were asked to complete a
questionnaire immediately after each
consultation and one week later.
This contained questions about the patient's
satisfaction with the consultation in terms of
the following factors:

Measures
The doctor's understanding of the problem.
This was measured by items such as 'I
perceived the general practitioner to have a
complete understanding' .
The adequacy of the explanation of the
problem. This was measured by items such
as 'I received an excellent explanation'.
Measures
Feeling helped. This was measured by the
statements 'I felt greatly helped' and 'I felt
much better'.
The results were analysed to evaluate
differences in aspects of patient satisfaction
between those patients who had received a
directive versus a sharing consulting style.

Measures
In addition, this difference was also
examined in relation to patient
characteristics (whether the patient had a
physical problem, whether they received a
prescription, had any tests and were
infrequent attenders).
Patient Satisfaction

The results showed that although all
subjects reported high levels of satisfaction
immediately after the consultation in terms
of doctor's understanding, explanation and
being helped, this was higher in those
subjects who had received a directive style
in their consultation.

Patient Satisfaction
In addition, this difference was also found
after one week.
When the results were analysed to examine
the role of patient characteristics on
satisfaction, the results indicated that the
directive style produced higher levels of
satisfaction in those patients who rarely
attended the surgery, had a physical
problem, did not receive tests and received
a prescription.


Patient understanding

Boyle (1970) asked patients to define a
range of different illnesses and found the
following:

Boyle (1970)

Illness to be defined % correct
Arthritis
85
Bronchitis
80
Jaundice
77
Palpitations
52
Roth (1979)
Roth (1979) found that although
patients understood that smoking
is causally related to lung
cancer, 50% thought that lung
cancer caused by smoking had a
good prognosis for recovery.
It was also found that 13% of
patients thought that hypertension
could be cured by treatment when
it can only be managed.

Patient recall
Bain (1977) tested recall of
a sample of patients who
attended a GP practice. The
following was found:

Instruction to be
recalled
% unable to recall
The name of the
prescribed drug
37
Frequency of dose 23
Duration of
treatment
25
Crichton et al. (1978)
Crichton et al. (1978) found
that 22% of patients had
forgotten their advised
treatment regimes after
visiting their GPs.

Ley (1989)
Ley (1989) found that the
following factors increased recall
of information:
Lowering of anxiety
Increased medical knowledge
Higher intellectual level (but see
below)
Importance and frequency of
statements
Primacy effects
Age has no effect on recall
success.

(DiMatteo & DiNicola 1982).

Cognitive and emotional factors in patients' recall
of information (DiMatteo & DiNicola 1982).
1. Patients forget much of what is told to them
2. Instructions and advice are more likely to be
forgotten than other information
3. The more a patient is told the greater the
proportion a patient will forget
4. Patients remember a) what they are told first and
b) what they consider to be important
5. Prior medical knowledge aids recall.

(DiMatteo & DiNicola 1982).

1. Intelligence is not a factor (but see above)
2. Age is not a factor
3. Moderately anxious patients recall more
than highly anxious patients
Homedes (1991)
200 variables affect compliance.
Characteristics of the patient
Characteristics of the treatment
regime
Features of the disease
The relationship between the health
care provider and the patient
The clinical setting.

Becker and Rosenstock (1984)

1. Evaluating the threat.
Seriousness and vulnerability are taken into account.
Being overweight would make you more vulnerable
to a heart attack.
A heart attack is serious.
The patients relative youth would mean he or she is
less vulnerable.
And so on.
Becker and Rosenstock (1984)

Seriousness and vulnerability being high would be a
good predictor of the likelihood of action.
However, there are other factors that need to be
taken into account.
A recent media campaign would be a cue to action.
The patient would need to work out the costs and
benefits of the treatment as well.

Becker and Rosenstock (1984)

2 Cost-benefit analysis.
Will the benefits outweigh the costs?
Barriers (or costs) might be financial,
difficulty getting to a health clinic, not
wanting to admit that they are getting old.
Benefits would be improved health, less risk
from illness and less anxiety.

(Becker 1976).
Perceptions of severity and susceptibility by
the patient are related to compliance
(Becker 1976).
(Becker 1976).
Patients who believe they are likely to
become ill and that this eventuality would
have negative consequences are more likely
to take some action.
Simple beliefs regarding the likelihood that
medication will improve the patient's
condition are very potent determinants of
compliance (Becker 1976).
Actual severity of an illness is not related to
compliance, but patient perception of
severity is.

Abraham et al (1992)
Abraham et al (1992) studied 300 sexually
active Scottish teenagers.
The seriousness of AIDS and the perceived
vulnerability of contracting the illness were
not the factors that influenced the teenagers.
The awkwardness of use and the likely
response from their partner, were seen as
costs that outweighed the benefits.
Abraham et al (1992)
The teenagers therefore tended not to use
condoms!
It would make sense to concentrate
advertising campaigns on the barriers to
condom use.

Problems
It is difficult to assess the health belief
model as it is difficult to measure variables
such as perceived susceptibility.
Habits, such as cleaning your teeth are not
easily explained by the model.
The model has limited predictive value, but
can be useful when trying to explain
somebody's behaviour.

(Becker 1974).
Any question of safety of treatment, side
effects, or distress associated with treatment
become very powerful suppressers and
reduce the likelihood that patients will do as
they were told (Becker 1974).

(Becker 1974).

The Health Belief model is a comprehensive
model.
Revisions in the model have expanded its range to
include intentions as well as beliefs (Becker
1974).
Other models that are less comprehensive are the
theory of reasoned action, protection motivation
theory, Naive health theories and subjective
expected utility theory.

Naive health theories.

Patients often develop their own incorrect
theories about their illnesses.
Such theories develop because a particular
behaviour has become erroneously
associated with an improvement in their
condition.
Naive health theories.
Such beliefs interfere with the
understanding of the doctor's instructions.
The instructions are interpreted so as to
accord with their naive health theory
(Bishop and Converse, 1986).

Naive health theories.
The model has two strengths.
One is that it explains why a patient who
intends to comply actually does not.
Secondly, the model is easily testable.
Rational non-adherence

Sometimes the side effects of a treatment can be
so devastating, that the patient decides, quite
rationally, not to proceed with the treatment.
Bulpitt (1988) medication used for the treatment
of hypertension reduced the symptoms of
depression and headache.
However, the men taking the drug experienced
increased sexual problems (difficulty with
ejaculation and impotence).
Rational non-adherence

Chapin (1980) suggested that 10% of
admissions to a geriatric unit were the result
of drug side effects.
Most non-adherence in arthritis patients
was owing to unintentional reasons (e.g.
forgetting); the common intentional reasons
were side effects and cost (Lorish et al,
1989).

Other useful concepts

1. Behavioural explanations - habits, imitation
(young smokers copying peers), reinforcement
(short term treatment will provide this, but long
term treatment would not).
2. Defence mechanisms - e.g. smokers might use
avoidance by avoiding information about the
harmful effects of smoking. Also, they could use
denial, pretending that smoking is harmless.
Other useful concepts

3 Conformity - e.g. men acting hard in front
of their mates, and therefore not complying
with their doctor's requests.
4 Self-efficacy (believe they can do
something about the problem) and locus of
control (feel that they have some control
over the illness).

Self-efficacy and conformity

It is better to have a self-efficacy that is
slightly higher than one's true ability.
This will give one the confidence to
undertake a task and make them resilient to
giving up.
Self-efficacy and conformity

We assess our self-efficacy by:
Observing others
Social and self-persuasion
Monitoring our emotional states
Payne and Walker (1996)
Payne and Walker (1996) suggest that
because people who have low self-esteem
and low self-efficacy do not value their own
ideas, they are more likely to adhere to
medical advice because they value what the
doctor tells them more than someone with
high self-esteem.
Payne and Walker (1996)
Similarly, a number of factors have been
shown to be important in predicting the
likelihood that a person will conform (or
adhere), and one of these is if a person
perceives that someone else has greater
expertise than them (i.e. has a powerful
others locus of control).
This is often true of how people regard
doctors.
Another factor that affects conformity is
that people are more likely to conform if
they have relatively little information on
which to base their judgement the less
information, the higher the rate of
conformity.
This may seem counter-intuitive, but
combined with some of the other factors
already mentioned.
Payne and Walker (1996)
Payne and Walker (1996), argue that many
situations relating to patient adherence in
health care are like this.
Doctors tend to explain things to their
patients on a need to know basis, which
leaves patients with little real knowledge
about their condition or treatment.

Diabetes and Compliance

Pancreas produces the hormone insulin,
which is responsible for the storage and use
of glucose.
Diabetics either produce no insulin (Type
I), or do not produce enough insulin (Type
II).
Type I would require insulin replacement
by injection.
Diabetes and Compliance

Type II requires a good diet, weight
management and oral medication.
Too little glucose in the blood would lead to
a hypoglycemic attack ('a hypo'), which is
life threatening.
Too much glucose produces little
immediate effect (unless the patient has too
much glucose over a long period of time).
Diabetes and Compliance

The long term effects of too much glucose
is likely to be circulation and heart
problems (Bradley 1994).
Diabetics have to respond to the following
health requests:
Give themselves injections of insulin, on a regular
basis, using the correct dosage and in a hygienic
way.
Regularly test for the level of glucose in the blood.
Eat on a regular basis and regulate the intake of
carbohydrates
Visit a health centre for a general check up on a
regular basis.
Take regular exercise.
Avoid alcohol, as this lowers the level of blood
sugar.
Wing et al 1986
Table of non-compliance of diabetics
Unhygienic injections 80%
Wrong insulin dose 58%
Inappropriate diet 75%
Irregular diet 75%


Glasgow et al (1987)
Glasgow et al (1987) - Diabetics have more
difficulty following exercise and diet
advice.
Data was collected by the patients own 'self-
report'.
This method is unreliable.
Glucose-testing machines fitted with a
memory chip showed that patients were
inaccurate in their self-reporting.

Possible reasons as to why diabetics do not
comply might be:
Embarrassment of testing and injecting in social settings.
Lack of social support.
Belief that they do not need to test for glucose level, as
they can tell anyhow.
Swigonski (1987)
Swigonski (1987) found that social support
in kidney disease patients can have adverse
effect.
Such patients were more likely not to
comply with limiting their fluid intake.
This is because social occasions often
involve drinking!

Bradley (1994)
Bradley (1994) found evidence to support
the view that patients can be aware of their
glucose levels:
Some diabetics were very accurate at being able to do this.
Some believe they have this ability, but are not without
training.
Symptoms tend to be reliable for the individual, but vary
between individuals.
Most diabetics can learn to be aware of their blood-
glucose levels. (A good example of the application of
psychology).

Shillitoe and Miles (1989)
Shillitoe and Miles (1989) in defence of the
diabetics against unjust criticism:
They do not have a 'specific' set of guidelines to follow.
They follow some instructions and not others.
Treatment varies from day to day, depending on many
different factors (e.g. exercise, infection, etc.). This makes
it difficult to define and measure compliance.

Old People and compliance
Kaplan et al (1993)
Difficulty in understanding and following
complex instructions.
Difficulty in opening medicine bottles (e.g.
child-proof caps).
Range of medicines increase the risks of side-
effects.