Becker 1980
Becker 1980
Becker 1980
2, Winter 1980
S T R A T E G I E S FOR E N H A N C I N G
PATIENT C O M P L I A N C E
Dr. Becker is Professor, Department of Health Behavior and Health, Education, University of
Michigan, School of Public Health, 1420 Washington Heights, Ann Arbor, Michigan 48109. Dr. Maiman
is Assistant Professor, Department of Pediatrics, University of Rochester, School of Medicine, 601
Elmwood Avenue, Rochester, New York 14642. Work for this review was supported in part by Grant No.
5K04-HD00237 from the National Institute of Child Health and Human Development.
PROVISION OF INFORMATION
for correct compliance, but also to recognize that such information may, under
particular circumstances, be insufficient to produce adequate patient
cooperation; and (2) to look at other variables that may be associated with
communication of " b e t t e r " information to the patient.
A study by Tagliacozzo conducted at a large urban hospital's out-
patient clinic relates to the first point and concerns follow-up visit compliance
by patients with chronic conditions. 15 Although patients with considerable
disease experience showed no association between knowledge and compliance,
such association became quite significant both for patients with little prior
experience and for those cases where social factors interfered with making
clinic visits. Thus, providing information for individuals motivated to comply
but ignorant of the correct procedures should be beneficial; however,
additional information about the regimen is less likely to enhance compliance.
An experiment by M c K e n n e y and associates illustrates the second
point. 16 Twenty-five of 50 hypertensive patients had monthly half-hour educa-
tional visits with the pharmacist in addition to their regular physician visits.
During the period of study, compliance rates for those in the "pharmacist"
group increased from 25% to 79% while rates in the control group did not
change. However, during the six-month period after the special education
effort was completed, compliance in the experimental group fell back to pre-
intervention levels. The transitory effect of the educational program suggests
that the pharmacist's extra interest and exhortation probably improved com-
pliance more than additional knowledge did. While either variable yields better
compliance, the particular interpretation is important, since each explanation
suggests a different focus for future attempts at intervention.
In any medical setting, some patients will not understand well what is
expected of them after the visit, and these patients naturally have much higher
rates of noncompliance than others do. Poor recall is part of the problem.
Studies have shown that, after five minutes, patients forget about half the
doctor's instructions,17 and remember best the material in the first one third of
the presentation.l~ Further, they recall the diagnosis better than they do the
prescribed therapy. 19 Such findings suggest that the provider speak briefly and
selectively, emphasizing information necessary for compliance clearly and
early in the communication, and then repeat that information, both orally and
through simple written instructions to which the patient may later refer (a
combination of oral and written instructions results in the highest levels of
patient information-retention). 17,~°,2ICarefully organizing the information also
seems important; in one study, the simple reorganization of a list of 15 medical
statements into labelled categories enhanced recall by 50 %. 17Specific and indi-
*idualized instructions are associated with better compliance.I°.22
O f course, patients differ widely in terms of how much they know (and
want to know), and they sometimes experience "information overload". 23,24
This difficulty can be overcome to some degree by focusing on absolutely ne-
cessary aspects of the treatment plan, and by avoiding more general
116 J O U R N A L OF C O M M U N I T Y H E A L T H
discussions of the disease, the action of the medication, and so forth, since this
type of information has not been shown to be related to compliance. On the
other hand, physicians frequently underestimate their patients' knowledge. ~5
However, these considerations aside, it is remarkable how much simply
modifying features of the communication can often raise patient compliance
levels. For example, in an experiment conducted with female subjects on a
weight-loss diet, Ley discovered that the group given a highly readable, well-
organized and repetitious leaflet experienced mean weight reductions
averaging about twice those achieved by their peers (who had received the
more usual type of leaflet). ~6
Similarly, one often observes a breakdown in doctor-patient communi-
cation when the patient does not know the relevant vocabulary. ~7 For example,
a study of communication between pediatricians and mothers demonstrated in-
adequate comprehension of such terms as "follow", "incubation period", and
" w o r k u p " , suggesting that even commonly used medical terms may require
explanation or substitution. 9 And, in a study of patients' interpretations of
written prescription instructions, Mazullo and associates found that 25 % of the
subjects interpreted the phrase " e v e r y six hours" as meaning " t h r e e times a
d a y " (since they sleep at night); " a s needed for water retention" was thought
to mean that the pills would be used to cause water retention. 28 Avoidance (or
full explanation) of medical terms is therefore strongly encouraged.
Health education can also successfully influence appropriate use of
medical services. Thus, for example, several studies found that education
resulted in a greater number of clients making use of a multiphasic screening
program in an H M O , ~9 and in more self-referrals to a venereal disease clinic? °
Similarly, such approaches have also accomplished desired decreases in utiliza-
tion. Egbert and associates randomly assigned 97 patients scheduled for
elective intra-abdominal surgery into experimental and control groups. 31 The
experimental subjects were told about the pain they would likely experience
(cause, location, duration, severity), and about how, through special breathing
exercises, they could reduce the pain; the controls were not told about post-
operative pain (the surgeons were unaware of any patient's study group
assignment). Results showed that patients in the experimental group requested
50% fewer narcotics for pain relief, and were discharged, on the average, 2.7
days sooner than the controls. Levine and Britten showed 45 hemophiliacs and
their families how to recognize symptoms requiring infusions and instructed
them in venipuncture techniques; they found a resultant reduction in total days
hospitalized from 432 in the previous year to 42 in the first poststudy year, as
well as 75% reductions both in absenteeism from work or school and in
outpatient visits? 2 By transmitting relevant instructions via a special telephone
hotline, one group reduced the diabetic coma rate by two-thirds? 3 Other
education efforts have effected lower utilization rates and improved regimen
compliance for patients with congestive heart failure34; for "worried well"
patients35; for asthmatics36-3a; and for persons with colds.39 O n the basis of these
Becker, Maiman 117
and other investigations, a strong case can be made regarding the potential of
education for enhancing cooperation and for reducing health care costs. 4°
Supervised practice of the activities that the prescribed therapy demands
also increases adherence. 41 This is true even for modification of such risk
factors as smoking or inappropriate eating behaviors, where the individual may
already be motivated to alter his/her lifestyle, but lacks the skills needed to
begin or to continue an appropriately altered behavior pattern. In such cases, it
appears necessary to train the individual in self-discipline through such means
as practice sessions and providing reinforcements. 42
Finally, simply reminding patients of upcoming appointments can
enhance compliance. Mail and telephone reminders have been used
successfully in such diverse areas as prenatal and well-child visits, medical and
dental checkups, and in obtaining annual Pap smears, 4~-47and have a clear,
beneficial influence on appointment-keeping behavior. 48-51 Foote and Erfurt
achieved a considerable increase in blood pressure control among hypertensive
patients through a program using mail and telephone follow-up 52
A L T E R I N G C H A R A C T E R I S T I C S OF T H E R E G I M E N
Second, one should try to reduce the length of therapy and bring the
condition under control as early as possible. Follow-up visits should be sche-
duled soon after the initial visit in those instances where progress can be
demonstrated to the patient. This would provide the patient with a feeling of
accomplishment and a sense of the treatment's importance.
Third, if alterations of critical behaviors (e.g., diet, exercise, smoking)
are to be requested, the practitioner should attempt making these changes
gradually over the course of several visits, taking the behaviors one at a time,
reinforcing whatever compliance is achieved, and only then adding the next
objective, s6 In this " s h a p i n g " process, the patient "proceeds in a stepwise
fashion to build his behavior repertoire, achieving a series of interim criteria
until he has attained full performance of the therapeutic tasks".1
Fourth, several investigations have improved compliance by "tailor-
ing" or linking the medication schedule to the patient's regular daily activities,
thus increasing its convenience and making it more difficult to forget.~4,~7.58For
example, Hallburg found that tailoring prescribed medication regimens to the
living patterns, habitual behaviors, and physical functioning abilities of elderly
ambulatory patients was effective in reducing serious medication errors59; and
Haynes and associates significantly improved compliance of hypertensive men
with their medication regimens by employing a multidimensional strategy that
included matching medication administration times to daily patterns and
habitual behaviors. 6° The practitioner should also seek other ways to make
compliance easier, such as convenient "dose-packaging" of the medication, or
the possibility of dispensing a medication directly from the clinic so that the pa-
tient can avoid a lengthy wait at the hospital pharmacy. 13
Fifth, one may wish to employ "graduated regimen implementation",
which successively introduces treatment procedures in an increasing order of
difficulty as the patient demonstrates proficiency in each prior component. An
example of this procedure would be gradually increasing medication doses
(i.e., n u m b e r of times a day and/or the quantity of medication taken) or
systematically increasing self-management requirements (e.g., gradually in-
creasing urine testing by diabetic patients from once a day to the desired fre-
quency). Dunbar has used this strategy in an experimental study of
cholestyramine administration. 61 Using a baseline diagnosis of daily
medication-taking over the three-week period, and obtaining prior information
concerning number of medication packets taken, time of administration, and
enhancing or inhibiting situational factors related to taking the medicine, Dun-
bar instructed each experimental subject to take a number of packets equal to
or slightly less than the baseline average and to administer the daily medication
at the most frequent baseline time. By gradually increasing the dosage and ad-
ministration times, she eventually placed the subjects on the full dose regimen;
by this procedure, Dunbar achieved a 75% compliance rate (and lowered
cholesterol levels).
Becker, Maiman 119
Sixth, the physician may be able to reduce the cost of the treatment
plan to the patient by such procedures as prescribing generically, avoiding un-
necessary or over-the-counter prescribing, checking for possible coverage by
the patient's health insurance, and encouraging the patient to compare pre-
scription rates at different pharmacies.
of the problem (e.g., " I can't have high blood pressure because I ' m not the
nervous type," or " m y child can't have the flu because he's had it before and
you don't get that twice--it's like measles"). These beliefs have multiple
origins (e.g., from cultural subgroups, parents' beliefs, prior experiences with
an illness, misinterpretation of factual information or acceptance of erroneous
information from nonmedical sources), and the existence of a great variety of
problematic health beliefs is well established. 74
Second, incidents may occur during the history-taking or physical
work-up that the patient interprets in such a manner as to weaken his con-
fidence in the diagnosis (e.g., " I came in complaining of a sore throat, but the
doctor spent a lot of time checking my ears and decided I have an ear infection;
well, he's wrong--it's my throat that hurts"). And then there is a well-
documented difficulty most persons have in being totally candid with their
physicians about everything worrying or bothering them. Patients frequently
are reluctant to trouble a busy professional with their minor aches and con-
cerns (embarrassment, fear of being labelled hypochrondriacal, and the social
distance between the professional and the lay patient also play roles in en-
couraging reticence); nonetheless, these problems and symptoms continue to
worry the patient. Thus, if the physician arrives at a diagnosis without happen-
ing upon the undisclosed concern, the patient sometimes feels that the
diagnosis must be inaccurate or incomplete, since it did not include (and
therefore did not explain) the withheld problem.
Third, not infrequently patients reject an unanticipated diagnosis too
painful to accept. They often react initially to a life-threatening illness by deny-
ing they have it 75 (a similar denial process leads to delay in seeking care for
symptoms related to serious diseases76). A national study of health beliefs has
shown that people accord to others a greater risk of contracting illnesses than
they are willing to estimate for themselves. 77
The degree to which a provider can modify health beliefs is more dif-
ficult to assess than the extent to which more (and better) information can be
transmitted or characteristics of the regimen changed. Nonetheless, research
has demonstrated that these attitudes and perceptions can be altered; and, by
learning which of these beliefs is below a level presumed necessary for com-
pliance, the provider can tailor intervention to suit the unique needs of each
patient. Thus, it is recommended that more attention be paid to both monitor-
ing and motivating the patient along these belief dimensions. (e.g., does the
patient care about health; agree with the diagnosis; perceive the condition as
very serious, or not at all serious; feel the recommended therapy will work; fear
medication side effects; feel the regimen will be too hard to follow?) ~3 Such a
"compliance-oriented history" should be viewed as a critical extension of the
usual medical history and be made a routine part of the examination process.56
Jenkins suggests that "attention to the 'health belief model' during the
diagnostic phase will identify what content should be emphasized in teaching
about the specific diseases to be prevented or treated and the specific health
Becker, Maiman 121
Some have argued that, other things being equal, patient acceptance of
physician-recommended modifications in lifestyle (e.g., smoking cessation,
weight reduction) is less likely when the patient sees the physician setting a
poor personal example. 96 Others concerned with physicians as role models for
lay persons have found that physicians often tend to seek medical-interventive
solutions to their own health problems even when they are common ailments,
normally expected to disappear without treatment. 97
PATIENT-PROVIDER CONTRACTS
Hypertension
Findings from a diagnostic baseline survey of outpatients with primary
hypertension revealed that the respondents indicated confusion about their
therapeutic regimens and difficulty fitting the regimens into their daily living
patterns. Further, the majority (70 %) reported a lack of family understanding
and support, and felt the need for a family member to know more about
hypertension. The data provided Green and associates with the basis for con-
structing a three-stage sequential intervention program consisting of an exit in-
terview to clarify the therapeutic regimen, a home visit to increase family sup-
port and understanding (using an adult 16 years or older identified as having
the most frequent contact with the patient), and small-group discussions to in-
crease patient feelings of self-control over their blood pressure. 1~9,~2°The in-
tervention program was used with 400 patients and was evaluated for its effect
on three behaviors (compliance with medication regimens, weight reduction,
and appointment keeping) assumed to be associated with blood pressure
control.
Analyses revealed the combination of exit interview and family-
support intervention to be the most effective strategy for enhancing compliance
with the medication regimen; however, the home visit alone achieved almost
the same level of compliance. 1..,1 With respect to weight reduction, the exit in-
terview proved to be the most effective intervention, w h i l e the home visit
(social support training) demonstrated only a modest effect on weight loss. A
ratio of appointment-keeping at the hypertension management clinic was
calculated for each subject by dividing appointments kept by appointments
scheduled during the study period. For this outcome measure, the social sup-
port training most effectively increased the number of patients keeping their
appointments. The greatest improvement in blood pressure control occurred in
the groups assigned to all three interventions. Looked at individually, the fam-
ily support intervention achieved a modest increase in control and the small-
group approach exhibited a slightly greater impact; the exit interview failed to
demonstrate any change in blood pressure control.
Arthritis
Oakes and associates retrospectively studied the contribution of family
expectations of compliance with actual use of a hand-resting splint regimen by
Becker, M a i m a n 129
rheumatoid arthritis patients; they found that, regardless of age, sex, or social
class, patients who felt their family members expected them to wear the hand-
resting splint were more likely than other patients to comply with the treatment
regimen. 122 Ferguson and Bole have also demonstrated the complex ways in
which family support influences compliance by arthritis patients with recom-
mendations about aspirin, exercise, and splints. 123
CONCLUSION
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