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 recommend medication other medical and laboratory assessments diet life style adjustments counseling 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 involves Beliefs: 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 follow Restrictions 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 difficulties Complex set of prescriptions Prescriptions that cause discomfort or distress  Previous failure in following the recommended prescription If 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 powers Socially 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 skills Authority 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 understanding If low, compliance will decrease  The patient’s personality Conformist 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-compliance Patient 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 severity Treatment for less severe illnesses is not taken as seriously  Acute versus chronic illness Mild 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 thinking The 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 patients Family 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 prescriptions Clear, 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 illness Charts, files Regular check-ups Self-generated care and self-management Encourage 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?