| It is not enough to prove
a thing. One must |
| also convince others
about it. |
|
Friedrich Nietzsche
|
The term "compliance" arose
at the beginning of the 70's, at a time when the first systematic studies
were initiated to answer the question: "How many of the patients who are
advised to do something by their doctor, actually do it?" Compliance should
not be confused with training, instant obedience or patronizing the patients.
In the widest sense, compliance means cooperation as a result of a partnership-like
relationship of doctor and patient.
Compliance is the most important
result of successful communication between doctor and patient. One of the
central
tasks of the discussion between doctor and patient is to achieve compliance.
The leading American researcher in compliance, A.R. Jonsen summed it up
as: "Compliance is really less the result of ethics but much more that
of the art of speech."
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The problem of non-compliance
Many studies have revealed that
non-compliance is one of the great practical problems in medical practice.
Compliance research has shown that non-compliance is far more extensive
than previously thought:
| • |
35-40%
of all prescribed medication are not taken (the estimated cost for West
Germany was estimated to be about 5-7 milliard DM per year). |
| • |
Even medication
which is considered vitally important is taken regularly only at rates
under 50%. |
| • |
Non-compliance
rates of 50-80% are found amongst hypertensives. |
| • |
Diabetic women
eat 100-200 kcal per day more than non-affected women of the same age. |
| • |
Non-compliance
for pre-natal exercises is about 50 %. |
Why is it that non-compliance
is so widespread? On superficial consideration, one could come to the conclusion
that non-compliance is not abnormal, but far more likely to be taken for
granted. Is however non-compliance really only the result of mankind's
weak nature that everyone falls back into old habits, and it has something
to do with the fact that forgetfulness is a natural phenomenon of existence?
On closer examination it
is clear that these explanations do not hold water. A person is suffering;
he finds a doctor, and visits him with the objective of getting help; the
doctor makes an effort to make a clear diagnosis and gives the patient
advice based on the diagnosis - but the patient does not follow this recommendation.
How can this behaviour be explained?
First let us look at a real
example:
A top manager had been feeling
under stress for several months. He woke with a bit of a headache every
morning as well as feeling slightly dizzy. As a result of pressure from
his family, and because a large special project of the firm had to be completed,
he visited his doctor. He did not really expect that anything dangerous
would be found. Repeated blood pressure measurements showed readings about
190/120 mm Hg. The diagnosis appeared to be long-established hypertension.
The doctor told him that the "raised blood pressure just had to be treated",
as such levels were "very unhealthy"; in the worst case cardiac infarction,
strokes and circulatory problems could result. Treatment with medication
was started. The patient felt worse, although the blood pressure dropped
into the normal range. He noticed increased tiredness, dizziness on rising,
as well as decreased potency. He was told by the doctor that he "must definitely
continue nevertheless" with the medication. It became more difficult to
do what he had to at work. He took his medication less and less regularly,
and did not feel so bad after all. One day it seemed as though the blood
pressure problem was completely forgotten.
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Causes of non-compliance
Some of the most important causes
of non-compliance can be seen in the example described above:
| • |
The
expectations
of the patient were not fulfilled. He was expecting to hear that
he was basically healthy. Instead of that, he had to undergo a multitude
of tests, accept a diagnosis of disease which he had not reckoned with,
and to hear the advice that he had to take tablets "for the rest of his
life". |
| • |
There was a marked
discrepancy between the subjective estimation of the severity of the
illness and the objective findings. |
| • |
The patient did
not
have the feeling that he was really threatened by his illness. |
| • |
There was no
major suffering. |
| • |
A trusting
relationship did not develop between the patient and the doctor
who treated him. |
Non-compliance is the result
of demotivation in the sense of unsuccessful motivation. That a
patient visits a doctor because he is seeking help, but does not follow
suggestions for treatment, has been described by L. Festinger as the psychological
phenomenon of cognitive dissociation theory. Everybody strives to
be free of inconsistencies in his cognitive system. He wants cognitive
elements to be consistent. If however two cognitive elements (opinions,
beliefs, what is thought to be true) have contradictory contents, cognitive
dissociation occurs which creates internal pressure. The cognitive dissociation
is only resolved by removing the contradictions between the cognitive elements,
and only this releases the internal tension.
If the patient has the impression
that he is not ill and expects that his slight headache will only turn
out to be an insignificant finding, but instead a moderate to severe hypertension
is discovered and he is given the recommendation for life-long medication,
this will lead to a cognitive dissociation. He is able to solve these internal
contradictions between his opinion and his acceptance by non-compliance.
The raised blood-pressure will be regarded as unimportant, a mechanism
by which the contradiction is made to fit the original expectation, and
as a result of which there is no need to take further medications.
Factors which can
individually lead to demotivation also play a decisive role in non-compliance.
Unsuccessful
motivation can be traced back to the following causes:
| • |
Unclear
formulation of the objective of therapy ("We must get the blood pressure
down") |
| • |
Impersonal
arguments, universally applied ("It's not healthy to be overweight") |
| • |
Hypothetical
arguments ("It's possible that you will lose a leg one day because
of the diabetes.") |
| • |
Creating anxiety
("If you carry on smoking like this, I'll only give you 2 years more") |
| • |
Exaggeration
of the objectives ("You have to take these tablets 3 x daily from now
on - at breakfast, lunch and supper - for the rest of your life to combat
this problem") |
| • |
Lack of willingness
to compromise ("Either you follow this diet or ...") |
| • |
Dealing in
various realities (the patient finds himself in a life crisis which
he would like to discuss, but receives instead a prescription for a trivial
finding) |
Groups working in America,
Austria and Germany in the last few years have shown that factors which
determine non-compliance can be placed in one of 5 groups:
| 1. |
Factors
which are grounded in the behaviour and the personality of the doctor |
| 2. |
Factors which
depend on the patient |
| 3. |
Manner and content
of the doctor's instructions |
| 4. |
Factors directly
or indirectly dependent on the therapy |
| 5. |
Factors which
depend on the illness |
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The doctor as a cause
of non-compliance
The credibility of the
person giving advice is a condition for the patient accepting this advice.
The credibility is in turn dependent on the specialized competence
which the patient ascribes to his doctor. However, even recommendations
which are based on specialized knowledge are only accepted if there is
a certain amount of trust between the patient and the doctor who
is treating him. There is a clear correlation between the degree of compliance
and the extent to which a patient trusts his doctor. If the patient has
a negative picture of medicine, this will also have a negative effect
on compliance.
Certain behaviour patterns
on the part of the doctor are particularly likely to encourage non-compliance:
| • |
cool
and distant approach |
| • |
"routine" discussion |
| • |
not answered
questions |
| • |
authoritative
behaviour |
| • |
not accentuating
the importance of a prescription |
The more that the doctor
inspires a feeling of partnership and the less he uses authority,
the more the patient is willing to accept recommendations. Questionnaires
have revealed however that nearly 50% of all doctors believe in the authoritarian
approach (R. Schoberberger, M. Kunze).
Further important causes
of non-compliance are:
| • |
that
the doctor is poorly or not at all motivated |
| • |
that the instructions
are not clear, or are misunderstood |
| • |
attacks on
the feelings of self-worth of the patient ("Others manage it faster
than you") |
| • |
strategies which
use shock tactics, threats or create anxiety |
| • |
overestimation
of the effect of a certain type of therapy |
| • |
insufficient
involvement of the patient's responsibility and independence |
| • |
increased authoritative
pressure |
| • |
cognitive or
emotional over-loading by the doctor |
A frequent cause of cognitive
overloading is the over-estimation of the extent to which a patient
can understand recommendations, as well as his attention span. By
their own admission, 7-53% of patients do not understand what the doctor
has told them. Studies have shown even higher percentages (53-89%), because
the patients believe that they have understood a recommendation,
even though this is not the case. Lay showed that the doctor's instructions
were forgotten in a frighteningly high proportion of cases (28-71%), and
the percentage rises as the number of items of information increases.
| Factors
which make non-compliance more likely |
|
A. Factors
which lie in the person or the behaviour of the doctor:
| 1. |
Authoritarian
behaviour |
| 2. |
Not fulfilling
the expectation of the patient |
| 3. |
Negative attitude |
| 4. |
Poor motivation
on his part |
| 5. |
Overestimation
of the therapeutic effect of treatment |
| 6. |
Not taking into
account the patient's sense of responsibility and independence |
| 7. |
Attacks on the
patient's self-respect |
| 8. |
Overloading the
patients' emotional or cognitive abilities |
| 9. |
Attempting to
motivate by inducing anxiety, shock tactics or threats |
| 10. |
Instructions
in specialized jargon |
|
B. Factors which lie
in the person or the behaviour of the patient:
| 1. |
General
negative attitude towards health |
| 2. |
Risks to health
not thought to apply |
| 3. |
Marked tendency
to prejudices and fixed ideas |
| 4. |
Passivity |
| 5. |
Hypochondria |
| 6. |
Limited cognitive
ability |
| 7. |
Limited ability
to concentrate |
| 8. |
Fear of addiction
to the medication |
| 9._ |
Considers that
the likelihood of side effects is high |
|
C. Factors which lie
in the instructions themselves:
| 1. |
Incomprehensible |
| 2. |
Excessive |
| 3. |
Imprecise |
| 4. |
Several different
instructions |
| 5. |
Instructions
with "the raised index finger", "you must ..." |
| 6._ |
Impossible instruction |
|
D. Factors which depend
directly or indirectly on the recommended treatment or changes in behaviour:
| 1. |
Stressful
or inconvenient forms of therapy |
| 2. |
Limitation of
quality of life |
| 3. |
Shocking effect
of the explanatory leaflet |
| 4._ |
Type and extent
of the side-effects |
|
E. Factors which depend
on the type of disease:
| 1. |
"Image"
of the disease |
| 2. |
Extent
of suffering |
| 3._ |
Objective severity
of the disease |
|
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Patient and non-compliance
Certain attitudes and preconceptions
on the part of the patient are often the cause of poor compliance. It is
usually very difficult to surmount these barriers, and it needs a particularly
persistent long-term intervention. The basic problem is that nobody can
be motivated against his will over a prolonged period, and attempts to
motivate in the face of tendencies, prejudices and habits meet the greatest
resistance.
The most important practical
reasons for poor compliance, which lie with the patient are:
| • |
A
generally
negative attitude towards health; the lower the importance of health
on the personal scale of values, the less the chance that he can be motivated
to undertake medical treatment. |
| • |
A playing
down of the risks to health. This often arises from defense mechanisms.
Although risks to health are accepted generally, they are not applied
to the patient himself. It should be pointed out in passing, that this
behaviour is very prevalent in doctors. |
| • |
A high level
of prejudices and fixed ideas. These are at the root of many pseudo-arguments
such as:
- "Everything has been alright
so far ..."
- "One can't live for health
alone ..."
- "Why should I poison myself
with lots of tablets ..."
- "I balance this with sport
..." etc. |
| • |
A passive
attitude. This can be favourized by excessively generous health insurance.
Such a patient tends to accept therapy which does not involve the use of
self-initiative, to put off important treatment and to put the responsibility
for their health problems into the laps of others. |
| • |
A high anticipation
of side-effects. This depends on the type of medication, the extent
of the explanation, on those around the patient, and not infrequently from
the fear of becoming addicted to the medication. A representative sample
of young people between 12 and 15 years old showed that nearly all believed
that all medications have dangerous side effects. |
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Instructions and
non-compliance
Poor instructions are
one of the major causes of non-compliance. The success of an instruction
mostly depends on the content, but also the extent and the way it is formulated
and given. The following forms of instruction are unsuitable
for motivation:
| • |
The
incomprehensible
or misunderstood instruction. The more specialized terms are used,
the more that the doctor uses "scientific" speech, and the more that the
language of the doctor diverges from that of the patient, the more the
instruction is likely to be misunderstood. Specialized jargon does not
only include technical terms in the narrow sense but also general medical
jargon. There are many terms which the doctor takes for granted as being
used in normal speech, which can be completely incomprehensible for the
patient ("regular application", "prognostic significance", "ubiquitous
effect"). |
| • |
The excessive
instruction: the more information that an instruction contains, the more
the likelihood of misunderstandings and the higher the extent to which
it will be forgotten. It is difficult for a patient facing an illness for
the first time to sort out the importance of each instruction when they
are multiple. The order in which instructions are given plays
a role in the way they are remembered; a recommendation given at the beginning
is twice as likely to be remembered as one in the midst of a series of
instructions. |
| • |
The imprecise
instructions: this does not only mean imprecision of an instruction
and the lack of quantitative information, but also instructions that the
doctor would not think could be misunderstood, but which can mean something
else to the patient, such as:
"You should phone immediately
if side effects occur ..." instead of "if the motions become black ...",
"if you become feverish ...", "if you notice a rash ..."
"Often put your legs up"
("How often?", "For how long?", "How high?")
"If you become infected,
you must increase the dose ..." (instead of "If you cough, or have a cold
or fever ...") |
| • |
So-called "broad-spectrum
instructions". Here recommendations are so imprecisely formulated and
so general that it is questionable whether they can be followed at all:
"Don't let things get on
top of you, even though it's bad."
"Stress is very bad for
you, so try to avoid it whenever possible, both at work and at home."
"Try not to take everything
to heart." |
| • |
Instructions
delivered with the index finger raised. Lecturing or preaching (instead
of recommending actions based on appropriate facts) does not usually result
in sustained effects. The danger of the so-called "pulpit syndrome" is
that either the words delivered from above do not fall down or are not
picked up from below, and are of little effect in either case. |
| • |
The illusionary
instruction: this acts against the principle that the objective
of motivation not only has to be recognizable and worthwhile, but also
attainable.
The most common causes are attitudes to illness from differing realities,
overestimation of the efficacy and usefulness of a procedure or unilaterally
pushing of a certain form of therapy. Although taking 18 tablets a day
can be fully justified on pharmacological and pathophysiological grounds,
this usually fails in practice. |
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Recommendations for
therapy and behaviour as the cause of non-compliance
The way in which therapy or
changes in behaviour are recommended is also decisive in the extent of
compliance. A high non-compliance is to be expected where:
| • |
The
type of therapy is stressful or requires special effort:
For example, most medications are supposed to be taken at times which do
not fit into a daily routine (i.e. 8 am, 4 pm and midnight); some recommendations
may not fit individual situations of the patient (at work, during journeys,
shifts), or may actually interfere in daily life (dosed aerosols, suppositories,
drops). The taste, shape and size, and smell of medications also play a
role. |
| • |
Procedures which
affect
"quality of life" to a significant degree; this includes all recommendations
which affect consumption or behaviour during time off. |
| • |
Formulation of
the information in the leaflet accompanying medications; the detailed
list of all of the possible side-effects has a shocking effect. Reports
which appear in the media, along with an increasingly critical approach
on behalf of patients which strengthens the desire for information, mean
that the explanatory leaflet becomes more and more a source of uncertainty
and nurtures a suspicious behaviour towards medication. In spite of extensive
opinion to the contrary, actual side-effects have very little influence
on non-compliance. Studies have shown that side-effects (at 5-10%) were
at the bottom of the list of causes of non-compliance. Other controlled
investigations have shown that side-effects occur to the same extent in
both those who can be relied on to comply and those who cannot. |
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Illness and non-compliance
It has not been clearly shown
whether or not there is a relationship between compliance and the objective
severity of the illness. Correlation between the severity of the illness
and the extent of compliance was shown in only 6 out of 13 studies. It
seems as if a milder degree of suffering encouraged non-compliance. Compliance
is especially poor in psychiatric patients with a schizophrenic personality
structure.
There is some discussion
about the relationship between the "image" of a disease and compliance.
Illnesses which with the general public have a high "attractively" (such
as cardiac disease and multiple sclerosis) are probably associated with
a higher degree of compliance than "unattractive" diseases, even if they
rank high in social medicine (i.e. hypertension, respiratory disease).
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Measures which can
encourage compliance
A seminar attended by both doctors
and patients (Eltville, 1985), gave patients an opportunity to formulate
their idea of the "ideal doctor", and also to consider what was more likely
or less likely to produce compliance. Summing up the extensive range of
suggestion doctors should:
| • |
not
be a school master, but still be able to be authoritative, |
| • |
probe into the
patient's personality, |
| • |
be somebody that
could be respected as an example, |
| • |
praise the patient, |
| • |
able to awake
hope that the therapy will be effective, |
| • |
give strength
at the point where the patient could not continue any longer (trusted confident,
helper, psychologist), |
| • |
make the illness
and the therapy understandable for the patient, |
| • |
give the patient
the opportunity to present his own view of the illness and his experience
of it. |
| In other words:
patients
are most likely to follow the recommendation of the doctor,
if he: |
| • |
shows empathy, |
| • |
approaches the
situation from that particular patient's particular stand-point, |
| • |
gives comprehensible
and well-founded recommendations, |
| • |
stands at
his side. |
|
The art of attaining the most
optimal compliance possible finally rests on exhausting all of the measures
which encourage motivation (see chapter on motivation  )
and on clearing away as many factors which lead to non-compliance as possible.
Various sorts of supporting
measures can also be used to achieve improved compliance. The involvement
of a partner or an other key-person in the therapy plan plays
a particularly important role, especially in the case of old or handicapped
patients where social isolation leads to a marked reduction in compliance.
The best person is one who is most concerned about the state of the patient's
health and who is acceptable to the patient. This can be a spouse, another
relative, a neighbor or a nurse. Involving this key person in the therapy
plan with regard to the non-medical measures (diet, physical activity,
cutting down on smoking etc) has a clearly motivating effect.
| Factors
which increase compliance |
|
A. Ground
rules:
| 1. |
The
patient must know what the objective is, and that it is both
attainable
and worthwhile |
| 2. |
Present positive
consequences |
| 3. |
Motto Victory
is possible! |
| 4. |
Take risks
and failure into account |
|
B. The optimal tool:
| 1. |
Instruct:
precisely, simply, comprehensibly, focusing on this particular patient |
| 2. |
Present a
standard |
| 3. |
One recommendation
is more likely to be followed than several |
| 4. |
The simplest
measure is the most effective |
| 5. |
Advice tailored
to the situation |
| 6. |
"One step at
a time" |
|
C. Supporting measures:
| 1. |
Written
information as memory aids |
| 2. |
Encourage checking
one's self |
| 3. |
Introduce a
helpful person |
| 4. |
Encourage independence
and self-responsibility |
| 5. |
Show willingness
to compromise |
|
|
Agreeing appointments for
checking progress has a cumulative effect: not only does this support
the patient in the belief that the doctor is really concerned about him
and interested in his progress, but it also affords the doctor the chance
to check compliance.
Compliance can be checked
not only by signs of the major pharmacological effect on the patient (i.e.
lowering of blood pressure), but also by the observation of specific side
effects (pulse rate with beta-blockers). Other expensive or non-routine
investigations such as blood level determinations (digoxin, theophylline,
phenytoin or tests for HbA1)
are of limited value for estimation of compliance. D.L. Sackett, one of
the leading American researchers into compliance, believes that direct
questioning of the patient is the best method of checking compliance.
Questions such as: "Many people find it difficult to remember to take their
tablets regularly. Do you find that you sometimes forget to take your tablets?"
are usually answered. However even though optimal compliance is an important
objective of the efforts of a doctor, it is just as important to remember
that ability and willingness to compromise is just as an effective
tool for guiding the patient.
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Linus
Geisler: Doctor and patient - a partnership through dialogue
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©
Pharma Verlag Frankfurt/Germany, 1991
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URL
of this page: http://www.linus-geisler.de/dp/dp15_compliance.html
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