COMPLIANCE TO THERAPY

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COMPLIANCE TO THERAPY
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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

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Defining the concept of compliance

• Research on compliance a social psychology
  issue
• Compliance is defined as the set of changes in
  an individuals 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
  groups 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)

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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 patients beliefs about therapy differ from
  the patients 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)

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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 patients
  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

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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 patients 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

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Factors involved in compliance

• Related to the patient (cognitive, moral,
  emotional)
• The patients level of understanding
• If low, compliance will decrease
• The patients 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

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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 symptomslow compliance
• Chronic illness with periods of severe acute
  symptomshigh compliance
• Impact of illness on patients 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

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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 physicians, because they have the same
  standpoint as the patient

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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

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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

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Rameckers 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?