“What appears to be non-compliance from a medical perspective may actually be a form of asserting control over one’s own behavior.”

I’ve always liked this characterization of patient adherence from Peter Conrad, The Meaning of Medication: Another Look at Compliance. It takes into account the fact that we’re dealing with people. What many times seems irrational to us as healthcare professionals, has most times been rationalized by the people for whom we provide care.

Human behavior is complex. Behaviorists describe human development as a 4-part process: physical (how we grow or age), cognitive (how we think), emotional (how we feel) and social (how we are valued). In listening to (researching) tens of thousands of patients – across therapeutic categories – over the last two decades, I’ve found that the following hold true:

How Patients Think: Most people know only the most superficial facts about their health. However, when presented with unexpected, personally relevant information many are motivated to act (e.g. adhere). Women were motivated to do annual mammograms when they were told how much “finding a lump the size of various millimeter-size pearls” equated to surviving breast cancer.

This is not to say that we all need a Ph.D. in what ails us. Judith Hibbard’s work at the University of Oregon suggests that “controlling costs and achieving health care quality improvements require the participation of activated and informed consumers and patients”. Her model focuses on patients acquiring knowledge, confidence and skills to act.

How Patients Feel: Fear operates to produce adherence in one patient and rapid non-persistence in another. Trust, on the other hand – in the healthcare system, our personal healthcare providers, and health products and services – resonates across audiences.

Most of us don’t see or directly interact with many of the stakeholders involved in our heathcare (e.g. our governments, managed care organizations, pharmaceutical companies). Instead, we see or talk to our personal physicians, pharmacists, and health agents who provide service. Trust in daily, health interactions is key to patient adherence to a recommended plan of action.

How Patients Are Valued: Personal and professional supports – spouses, parents, children, friends, co-workers, physicians – strongly influence our health decisions and behaviors. Where there is no or poor personal and professional support there is many times low patient adherence. On the other hand, when we feel valued and respected as a result of our health behaviors by those who directly care for and come into contact with us, we comply and persist with the behavior. Unfortunately, patients too frequently say they walk away from health exchanges feeling devalued or stigmatized.

How Patients Age: People that are sicker have typically developed patterns of thinking and behavior that make disease easier to deal with as part of daily life. Experience is the best teacher. In life-threatening and life-altering conditions the lessons comes fast – as does the incorporation of health routines into daily life. Patients benefit from access to “people like me”, but the access has to be practical for someone already taking on a host of new behaviors (e.g. going to the doctor, filling prescriptions, processing health claims).

A “Patient” Solution

Listening for the Problem: A JAMA study Soliciting the Patient’s Agenda found that physicians often redirect patients’ initial descriptions of their concerns (“after a mean of 23.1 seconds”). Patients allowed to complete their statement of concerns (“used only 6 seconds more on average than those who were redirected”) consequently, had fewer late-arising concerns. Although the article did not specifically address patient adherence, one has to imagine that solving the complaint of most concern to the patient rather than the problem the physician chose to solve would increase one’s motivation to act.

A Caring Voice & Climate: Miller and Rollnick’s work in Motivational Interviewing recommends a tone on the part of public health, health psychology, and medical professionals that is nonjudgmental, empathetic, and encouraging to patients. It allows patients to work through their ambivalence about behavior change. A 2002 Health Psychology Article examining Motivational Interviewing in Health Promotion: It Sounds Like Something is Changing further encourages health counselors to establish a non confrontational and supportive climate in which one feels comfortable expressing both the positive and negative aspects of their (adherence) behavior.

Maintenance Under Stress: Adopting a healthy behavior is difficult, particularly if you’re a “healthcare Rookie” (someone new to implementing a health behavior change), but Hibbard’s model suggest that sustaining the change under stress can be even more difficult. The stressor can be clinical (a co-morbidity), financial (job loss), lifestyle (divorce), emotional (stigma or societal pushback), health system-related (change in insurer), etc. in nature. Laying down the treatment plan is a first step; having the right monitoring and follow-on systems in place – at the moment the patent most needs prompting/encouragement– has also been shown be critical to patient success.

A take-home message from The 2003 World Health Report on Patient Adherence was that patients need to be supported, not blamed. The common belief that patients are solely responsible for taking their treatment is misleading and most often reflects a misunderstanding of how other factors affect people’s behavior and capacity to adhere to their treatment.

This entry was posted on Tuesday, October 20th, 2009 at 11:10 am and is filed under Drug Adherence, Patients. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.