PATIENT COMPLIANCE AND SATISFACTION

• Conditions such as diabetes, renal failure, hypertension, and chronic pain affect millions of individuals and the task of living with these illnesses can be summarized under the general rubric of “compliance”.

• Compliance vs Adherence Compliance has usually been defined in a general way such as by Haynes (1976): “the extent to which a person’s

behavior coincides with medical or health advice”. The measurement of compliance in clinical settings is, however controversial. There is often little agreement among health care professionals about what constitutes compliant behavior with any particular medical regimen.

• Turk et al. associates the term compliance with the traditional health care relationship within which the patient is a passive responder to the physician’s authoritarian demands. As they view this type of relationship as opposed to the alternative cognitive behavioral model they propose, they reject compliance in favor of adherence. Adherence denotes a collaborative, interactional relationship. Barofsky (1978) argues that in addition to the terms compliance and adherence can be added a third: “therapeutic alliance”. All these terms represent points along a continuum of social control. The medical professional-patient relationship inherently consists of varying degrees of external control of the patient’s life by the care provider over the course of treatment. Whereas compliance and adherence usually imply a standard external to both parties, therapeutic alliance implies a negotiated reciprocal agreement between patient and provider which may result from a developing positive social relationship.

The Extent of Non-Compliance

• Research in the area of compliance includes a wide array of subjects from one individual following the advice of one doctor to take antibiotics for a sore throat to the influence of public health policy on preventive health behaviors (i.e., developing exercise regimen, smoking cessation).

• Sackett (1976) suggests that 50 percent of the patients do not take prescribed medications. Medical appointments are missed from 20 to 50 percent of the time. Physicians show poor predictive ability in judging whether a patient will be compliant (Haynes, 1976). It is also generally accepted that compliance rates tend to decrease the longer the regimen must be followed. One study (Bloom, Cerkoney, & Hart, 1980) showed that fewer than 7% of the chronic diabetic patients fully compiled with medically recommended self-care procedures. These research results showing consistently low compliance rates are particularly significant because of the increasing evidence that certain behavior changes can have dramatic impact on the course of chronic disease.

Factors Affecting Compliance

• It is clear that compliance rates vary according to how they are measured. Patient self- report measures have been shown to be significantly inaccurate when compared with objective (e.g., blood tests) tests with the tendency for the more noncomplying patients to be the least accurate in their self description (Mazur, 1981). More objective measures have shortcomings also. Pill counts, for example, may be affected by patients simply discarding medication rather than their taking appropriate dosage. Since no one measurement method is without inadequacies, caution must be exercised in interpreting research results.

• Another set of factors affecting compliance could be referred to as individual factors and would consist of the patient’s perception of their illness and their sense of control over their condition. Such approaches are cognitive in emphasis and are designed with some modification to include the effects of external variables such as objective health state (Becker, 1974). Other theorists have taken a strict environmentalist view of compliance, viewing adherence to medical regimen as a series of behaviors controlled by externally generated rewards and punishments (Zifferblatt, 1975).

Intervention Strategies to Increase Compliance

• The improvement of compliance rates has been a major treatment concern in the field of health psychology. An assortment of behavioral techniques have been used with limited success. Among these methods are cueing, stimulus control techniques (i.e., flavoring pills to improve taste), self-monitoring methods (i.e., keeping records of pills taken) (Johnson, Taylor, Sackett, Dunnet & Shinizu, 1978), and reinforcement of medication use and symptom reduction (Haynes, 1976). In reviewing these various behavioral methods, Epstein and Cluss (1982) are critical of the research methods adopted in the studies and conclude that, in general, such techniques do not significantly improve compliance rates.

• Other treatment approaches have stressed informational/educational interventions (i.e, meetings with patients to discuss medication, telephone reminders regarding upcoming medical appointments). Such methods have not, generally, improved compliance rates (Kirscht & Rosenstock, 1979). Interventions aimed at improving patient-provider relationships have been identified as holding significant promise for future interventions (Stone, 1979). Here, improving effective communication skills of medical professionals would be the major treatment focus.

Adhering to Medical Advice

• Personality Patterns When the problem of compliance failures became obvious, researchers initially considered the concept of a noncompliant personality. According to this concept, people with certain personality patterns would have low compliance rates. If this concept is accurate, then the same people should be noncompliant in a variety of situations. However, little evidence exists to support this conclusion. On the contrary, some research indicates that noncompliance is specific to the situation (Luiz, Silbert, & Olshan, 1983) and that adherence to one treatment program is independent of adherence to others (Ogedegbe, Schoenthaler, & Fernandez, 2007). Thus the evidence suggests that noncompliance is not a global personality trait but is specific to a given situation. (Haynes, 2001).

• Emotional Factors Do emotional factors such as stress and anxiety relate to adherence? Some evidence suggests a positive answer to this question. A study that investigated the effects of stressful life events on subsequent exercise adherence (Oman & King, 2000) found that people who experience several stressful events are likely to drop out of an exercise program. Another study found that individuals taking antiretroviral medication for HIV infection who reported high levels of stress were less adherent (Bottonari, Roberts, Ciesla, & Hewitt, 2005).

• Personal Beliefs Some evidence suggests that patients’ personal beliefs are related to compliance. We have seen that the theory of reasoned action has some ability both to predict and to explain adherence and nonadherence and that perceived self-efficacy is an even better predictor. People who believe in their personal ability to perform the behaviors necessary to adhere to their medical regimen are more likely to do so. In general, patients’ beliefs are an important factor in adherence (Gans & McPhillips, 2003). Beliefs that affect adherence include a belief in the effectiveness of the treatment. Patients who believe that the recommended course of treatment (Gellaitry et al., 2005) or medications (Menckeberg et al., 2008) will be effective are more likely to comply with the prescribed regimen. Beliefs that treatment will be ineffective or even harmful are related to low adherence. This result appeared in studies with Japanese hospital patients (Iihara et al., 2004), African Americans with hypertension (Lukoschek, 2003), Swedish pharmacy customers (Mardby, Akerlind & Jorgensen, 2007), and individuals taking medication for osteoporosis (McHorney, Schousboe, Cline, & Weiss,2007).

Practitioner-Patient Interaction

• In addition to looking at disease characteristics and personal factors, researchers have studied patient-practitioner interaction and its relation to adherence and non-adherence. Practitioners who are successful in forming a working alliance with their patients are more likely to have patients who are satisfied and who follow their recommendations (Fuertes et al., 2007). Important factors in building successful practitioner-patient alliances include verbal communication and the practitioner’s personal characteristics.

• Verbal Communication Perhaps the most crucial factor in patient noncompliance is poor verbal communication between the practitioner and the patient (Cutting Edge Information, 2004). When patients believe that physicians understand their reasons for seeking treatment and that both agree about treatment, adherence increases (Kerse et al., 2004), but problems in communication present barriers to this understanding.

In Summary

• Several conditions predict poor adherence: (1) side effects of medication; (2) long and complicated treatment regimens; (3) personal factors such as old or young age; (4) emotional factors such as conscientiousness and emotional problems such as stress and depression; (5) personal beliefs that the treatment is ineffective or a lack of self-efficacy for performing the medical regimen; (6) economic barriers to obtaining treatment or paying for prescriptions; (7) lack of social support; (8) patients’ cultural beliefs that the medical regimen is ineffective; (9) poor patient-practitioner communication, including problems in verbal communication and patients’ perceptions of uncaring, incompetent, or disrespectful physicians. Researchers and practitioners need to understand that the factors identified as influencing adherence interact in complex ways. Table 4.1 summarizes the research on what factors predict and fail to predict adherence.

TABLE 4.1Predictors of Patient Adherence

Findings Studies

1. Disease Characteristics

A. Severity of illness

Illness interferes with appearance Increases compliance DiMatteo & DiNicola, 1982

Review of many disorders No relationship DiMatteo, 2004b

Patients’ perception of severity Strongly related to compliance DiMatteo et al., 2007

Pain with illness Increases compliance Becker, 1979

B. Side effects of medication

Unpleasant side effects with HIV drugs Decreases compliance Gellaitry et al., 2005;Herrmann et al., 2008

C. Complex treatment procedures

Increasing number of doses Decreases compliance Claxton et al., 2001; Piette et al., 2006

Findings Studies

II. Personal Factors

A. Increasing Age

Aging Curvilinear relationship Thomas et al.,1995

Older ages Decreases compliance Gans & McPhillips,2003

Adolescents

Growing older Decreases compliance DiMatteo,2004b; Ellis et al., 2008; Herrmann et al., 2008; Miller & Drotar, 2003; Olsen & Sutton, 1998

B. Gender

Keeping medical appointments Men and women equal Sola-Vera et al., 2008

Taking medication Men and women equal Anderson et al., 2005

Eating a healthy diet Women more compliant Chung et al., 2006; Laforge et al., 1994

Findings Studies

C. Personality patterns

Noncompliant personality Situation, not personality, influences adherence

Haynes, 2001; Lutz et al., 1983; Ogedegbe et al., 2007

D. Emotional factors

Stressful life events Decrease compliance Bottonari et al., 2005; Oman & King, 2000

Conscientiousness Increases compliance Goodwin & Friedman, 2006; O’Cleirigh et al., 2007; Vollrath et al., 2007

Depression Decreases compliance DiMatteo et al., 2000

Optimism Increases compliance Gonzalez et al., 2004

E. Personal beliefs

Self-efficacy Increases compliance Gans & McPhillips,2003

Belief in treatment effectiveness Increases compliance Gellaitry et al., 2005; Menckeberg et al., 2008

No confidence in treatment Decreases compliance Iihara et al., 2004; Lukoschek, 2003; Mardby et al., 2007; McHorney et al., 2007

Feelings of control Increases compliance Westerfelt, 2004

Findings Studies

III. Environmental Factors

A. Economic factors

Low income Decreases compliance Gallegos-Macias et al., 2003

Insurance fails to cover all prescription costs Decreases prescription filling and refilling

Gans & McPhillips, 2003Gellad et al., 2007; Ye et al., 2007

B. Social support

Low social support Decreases compliance Kyngals 2004

among adolescents

Living alone Decreases compliance DiMatteo,2004b

Support for specific health behaviors Increases compliance Ellis et al., 2007

C. Cultural norms

Belief in traditional healers Decreases compliance Kaholokula et al., 2008; Zyazema,1984

Acculturation to Western culture Increases compliance Barron et al., 2004;Novins et al., 2004

Culture places trust in physicians Increases compliance Chia et al., 2006

Physician’s stereotype of African Americans and low-income patients

Decreases compliance Van Ryn & Burke, 2000

Physician disrespect of African Americans, Hispanic Americans, and Asian Americans

Decreases compliance Blanchard & Lurie, 2004

Findings Studies

IV. Practitioner/Patient Interaction

A. Verbal Communication

Poor verbal communication Decreases compliance Cutting Edge Information,2004

Interrupting patients Decreases compliance Galland,2005

Agreement about treatment Increases compliance Kerse et al., 2004

Failing to receive expected information Decreases compliance Bell et al., 2002

Problems with language or terminology Decreases compliance Blanchard & Lurie, 2004;Castro et al., 2007;Charlee et al., 1996; Flores,2006; Rosenberg et al., 2007

B. Practitioner’s personal qualities

Patient’s confidence in physician competence Increases compliance Bendapudi et al., 2006; Gilbar, 1989

Friendliness Increases compliance Bendapudi et al., 2006; DiNicola & DiMatteo, 1984

Practitioner disrespect Decreases compliance Blanchard & Lurie,2004

Gender Female doctors provide information

Roter & Hall, 2004

How Can Adherence Be Improved?

• Knowing the barriers to adherence provides hints for improving patient compliance. Methods for improving compliance can be divided into (1) educational and (2) behavioral strategies. Educational procedures are those that impart information, sometimes in an emotion-arousing manner designed to frighten the noncompliant patient into becoming compliant. Included with educational strategies are such procedures as health education messages, individual patient counseling with various health care providers, programmed instruction, lectures, demonstrations, and individual counseling accompanied by written instructions. Haynes (1976) reported that strategies that relied on education and threats of disastrous consequences for nonadherence were only marginally effective in bringing about a meaningful change in patients’ behaviors; more recent reviews (Harrington, Noble, & Newman, 2004; Schroeder, Fahey, & Ebrahim, 2007) have come to similar conclusions of marginal or no effectiveness. Educational methods may increase patients’ knowledge, but behavioral approaches offer a more effective way of enhancing adherence. People, it seems, do not misbehave because they do not know better but because adherent behavior, for a variety of reasons, is less appealing.

• Behavioral strategies focus more directly on changing the behaviors involved in compliance. They include a wide variety of techniques, such as notifying patients of upcoming appointments, simplifying medical schedules, providing cues to prompt taking medication, monitoring and rewarding patients’ compliant behaviors, and shaping people toward self-monitoring and self-care. Behavioral techniques have been found to be more effective than educational strategies in improving patient compliance.

Reasons Given by Patients for Not Complying with Medical Advice

• “It’s too much trouble.”• “ I just didn’t get the prescription filled.”• “ The medication was too expensive, so I took fewer pills to make them last.”• “ The medication didn’t work very well. I was still sick, so I stopped taking it.”• “ The medication worked after only one week, so I stopped taking it.”• “ I have too many pills to take.”• “ I won’t get sick. God will save me.”• “ I forgot.”’• “ I don’t want to become addicted to pills.”• “If one pill is good, then two pills should be twice as good.”• “ I saved some pills for the next time I get sick.”• “ I gave some of my pills to my husband so he won’t get sick.”• “ They’re trying to poison me.”• “ This doctor doesn’t know as much as my other doctor.”• “ The medication makes me sick.”• “ I don’t like the way that doctor treats me, and I’m not going back.”• “ I feel fine. I don’t see any reason to take something to prevent illness.”• “ My doctor prescribes too many pills. I can’t afford all of them.”• “ I don’t like my doctor. He looks down on people without insurance.”• “ I didn’t understand my doctor’s instructions and was too embarrassed to ask her to repeat them.”• “ I don’t like the taste of nicotine chewing gum.”• “ I didn’t understand the directions on the label.”

Behavioral strategies for improving adherence

• Adherence researchers Robin DiMatteo and Dante DiNicola (1982) recommended four categories of behavioral strategies for improving adherence, and their categories are still a valid way to approach the topic. First, various prompts can be used to remind patients to initiate health-enhancing behaviors. These prompts may be cued by regular events in the patient’s life, such as taking medication before each meal, or they may take the form of telephone calls from a clinic to remind the person to keep an appointment or to refill a prescription. Another type of prompt comes in the form of reminder packaging, which presents information about the date or time that the medication should be taken on the packaging for medication (Heneghan, Glasziou & Perera, 2007). In addition, electronic technology can be useful in providing prompts.

• A second behavioral strategy proposed by DiMatteo and DiNicola is tailoring the regimen, which involves fitting the treatment to habits and routines in the patient’s daily life. Pill organizers work toward this goal by making medication more compatible with the person’s life, and some drug companies are creating medication packaging, called compliance packaging, that is similar to pill organizers in providing a tailored regimen (Gans & McPhillips, 2003). Another approach that fits within this category is simplifying the medication schedule’ a review of adherence studies ( Schroeder et al., 2007) indicated that this approach was among the most successful in increasing adherence.

• Another way to tailor the regimen involves assessing patients’ stages of change as depicted in the transtheoretical model and then orienting change-related messages to a patient’s current stage ( Gans & McPhillips, 2003). For example, a person in the contemplation stage is aware of the problem but has not yet decided to adopt a behavior. This person might benefit from an intervention that includes information or counseling, whereas a person in the maintenance stage would not. Instead, people in the maintenance stage might benefit from monitoring devices or prompts that remind them to take their medication or to exercise. Applying this approach to the problem of preventing the complications that accompany heart disease, a group of researchers (Turpin et al., 2004) concluded that tailoring adherence programs to patients’ levels of adherence was critical; patients who are mostly adherent differ from those who are partially adherent or nonadherent. Similar success occurred with a program to help people adhere to lipid-lowering drugs ( Johnson et al., 2006). These successes suggest that differences in stage of readiness to change require different types of assistance to achieve adherence.

Behavioral strategies for improving adherence (contd..)

• A similar way to tailor the regimen involves helping clients resolve the problems that prevent them from changing their behavior. Motivational interviewing is a therapeutic approach that originated within substance abuse treatment (Miller & Rollnick, 2002) but has been applied to health-related behaviors, including adherence (Resnicow et al., 2002). This technique attempts to change a client’s motivation and prepares the client to enact changes in behavior. The procedure includes an interview in which the practitioner attempts to show empathy with the client’s situation, discusses and clarifies the client’s goals and contrasts them with the client’s current, unacceptable behavior, and helps the client formulate ways to change behavior. Motivational interviewing has been used with patients with a variety of diseases, and a review of studies (Knight, McGowan, Dickens, & Bundy, 2006) indicated that the technique is effective.

• Third, DiMatteo and DiNicola suggested a graduated regimen implementation that reinforces successive approximations to the desired behavior. Such shaping procedures would be appropriate for exercise, diet, and possibly smoking cessation programs, but not for taking medications.

• The final behavioral strategy listed by DiMatteo and DiNicola is a contingency contract (or behavioral contract)- an agreement, usually written between patients and health care professionals that provides for some kind of reward to patients contingent on their achieving compliance. These contracts may also involve penalties for noncompliance (Gans & McPhillips, 2003). Contingency contracts are most effective when they are enacted at the beginning of therapy and when the provisions are negotiated and agreed upon by patients and providers. Even with these provisions, contracts have not been demonstrated to boost adherence by a great deal ( Bosch –Capblanch, Abba, Prictor & Garner,2007).

Patient Satisfaction

• Ley (1988) examined the extent of patient satisfaction with the consultation. He reviewed 21 studies of hospital patients and found that 41 per cent of patients were dissatisfied with their treatment and that 28 per cent of general practice patients were dissatisfied. Studies by Haynes et al. (1979) and Ley (1988) found that levels of patient satisfaction stem from various components of the consultation, in particular the affective aspects (e.g. emotional support and understanding), the behavioural aspects (e.g. prescribing, adequate explanation) and the competence (e.g. appropriateness of referral, diagnosis) of the health professional. Ley (1989) Also reported that satisfaction is determined by the content of the consultation and that patients want to know as much information as possible, even if this is bad news. For example, in studies looking at cancer diagnosis, patients showed improved satisfaction if they were given a diagnosis of cancer rather than if they were protected from this information.

• Berry et al.(2003) explored the impact of making information more personal to the patient on satisfaction. Participants were asked to read some information about medication and then to rate the satisfaction. Some were given personalized information, such as ‘If you take this medicine, there is a substantial chance of you getting one or more of its side effects’, whereas some were given non-personalized information, such as ‘A substantial proportion of people who take this medication get one or more of its side effects’. The results showed that a more personalized style was related to greater satisfaction, lower ratings of risks of side effects and lower ratings of the risk to health.

Patient Understanding

• Several studies have also examined the extent to which patients understand the content of the consultation. Boyle (1970) examined patients’ definitions of different illness and reported that, when given a checklist, only 85 per cent correctly defined arthritis, 77 per cent correctly defined jaundice, 52 per cent correctly defined palpitations and 80 per cent correctly defined bronchitis. Boyle further examined patients’ perceptions of the location of organs and found that only 42 per cent correctly located the heart, 20 per cent located the stomach and 49 per cent located the liver. This suggests that understanding of the content of the consultation may well be low. Further studies have examined the understanding of illness in terms of causality and seriousness. Roth (1979) asked patients what they thought peptic ulcers were caused by and found a variety of responses, such as problems with teeth and gums, food, digestive problems or excessive stomach acid. He also asked individuals what they thought caused lung cancer, and found that although the understanding of the causality of lung cancer was high in terms of smoking behaviour, 50 per cent of individuals thought that lung cancer caused by smoking had a good prognosis. Roth also reported that 30 per cent of patients believed that hypertension could be cured by treatment.

• If the doctor gives advice to the patient or suggests that they follow a particular treatment programme and the patient does not understand the causes of their illness, the correct location of the relevant organ or the processes involved in the treatment, then this lack of understanding is likely to affect their compliance with this advice.

The role of information in improving compliance

• Researchers have examined the role of information and the type of information on improving patient compliance with recommendations made during the consultation by health professionals. Using meta-analysis, Mullen et al. (1985) looked at the effects of instructional and educational information on compliance and found that 64 per cent of patients were more compliant when using information.

Recommendations for improving compliance

• Several recommendations have been made in order to improve communication and therefore improve compliance.

Oral Information

• Ley (1989) suggested that one way of improving compliance is to improve communication in terms of content of an oral communication. He believes the following factors are important:

• Primary effect-patients have a tendency to remember the first thing they are told

• To stress the importance of compliance• To simplify the information• To use repetition• To be specific• To follow up the consultation with additional interviews

Written Information

• Researchers also looked at the use of written information in improving compliance. Ley and Morris (1984) examined the effect of written information about medication and found that it increased knowledge in 90 per cent of the studies, increased compliance in 60 per cent of the studies, and improved outcome in 57 per cent of the studies.

• Ley’s cognitive hypothesis model, and its emphasis on patient satisfaction, understanding and recall, has been influential in terms of promoting research into the communication between health professionals and patients. In addition, the model has prompted the examination of using information to improve the communication process. As a result of this, the role of information has been explored further in terms of its effect on recovery and outcome.

Using information to improve recovery

• If stress is related to recovery from surgery, then obviously information could be an important way of reducing this stress. There are different types of information that could be used to affect the outcome of recovery from a medical intervention. These have been described as:

• (1) sensory information, which can be used to help individuals deal with their feelings or to reflect on these feelings;

• (2) procedural information, which enables individuals to learn how to process or the intervention will actually be done;

• (3) coping skills information, which can educate the individual about possible coping strategies; and

• (4) behavioral instructions, which teach the individual how to behave in terms of factors such as coughing and relaxing.

Understand the close relationship between compliance and satisfaction and illness outcome

Issues of Compliance

• The ultimate goal of any interaction between physician and patient is to ensure that effective treatment is provided. This leads directly to the issue of compliance with treatment recommendations.

• Poor compliance is a major problem in medical practice. It can be minimized or exacerbated by physician interventions and by the quality of the doctor-patient relationship (Fuller and Gross, 1990).As many as 50 percent of patients do not comply with treatment. One study showed that one third of patients complied with all treatment recommendations, one third complied with some recommendations, and one third were completely noncompliant (Sackett and Haynes, 1976). These figures do not change significantly with increasing severity of illness.

• The statistics are demoralizing; they suggest that a correct diagnosis and treatment strategy is only half the battle. Far more complicated is the effort to get patients to comply with recommended treatment. It is easy to become frustrated with patients who do not comply with recommendations; for example, the obese patient who will not lose weight, or the smoker who will not quit. More dramatic are patients who do not make important life changes after significant events, such as the patient who cannot slow down after a myocardial infraction.

• Change is a difficult proposition for everyone. The doctor who has had a serious illness or even a minor one will be in the best position to understand how difficult compliance can sometimes be. The simplest example of noncompliance might be the need for a full course of antibiotic medication to treat streptococcal pharyngitis. Every medical student knows the importance of completing the course of medication; yet, most can acknowledge how difficult it was for them to stick to the regimen without forgetting one or more doses.

Understand the close relationship between compliance and satisfaction and illness outcome

The most effective approach to the problem of noncompliance is to look at factors that may impede compliance and those that seem to enhance it (Stoudemire and Thomson, 1983). The factors are numerous and patient-specific, but they can be categorized (see Table 1-2)

Table 1-2 Factors Affecting Compliance

• FACTORS THAT IMPEDE COMPLIANCE

– Low level of subjective distress.– Denial of illness– Poor communication between physician and patient– Complex regimens.– Treatment that is embarrassing or humiliating.– Outside factors that make compliance difficult.– Patient’s perception that it is beneficial to remain ill.– Side effects that are significant for the patient.

• FACTORS THAT ENHANCE COMPLIANCE

– Good rapport between physician and patient– Simple regimens.– Clear instructions that patient can repeat back to physician.– Positive feedback for adherence.– Increased level of distress.– Decreased waiting room time.– Increased time with physician.– Family support and involvement.

Understand the close relationship between compliance and satisfaction and illness outcome

Factors Related to Noncompliance

• The patient may not feel ill. Patients have a hard time taking their antihypertensive medications because they don’t feel ill. Likewise, the patient being treated for an acute infection may stop taking medication as soon as symptoms are relieved.

• The patient may wish to deny the illness. Taking medication or following some other treatment regimen is a reminder of the illness. A simple solution is to become noncompliant.

• The patient may not understand the rationale for the treatment or how the medication is to be taken. This is particularly possible if the patient and physician do not communicate well.

• The patient may find the treatment regimen too difficult or disruptive to follow (Stone, 1979). One patient reported that several different physicians were treating her, and she was asked to take 12 different medications throughout the day.

• The patient may feel embarrassed or humiliated by the treatment recommended. This may be particularly true for young people who do not want to be seen as sick by their peers. They may find it difficult to take medications at school and therefore become noncompliant or “forget” to take their medications during the day.

• The patient’s family, work pressures, or other outside factors may limit compliance. For example, the woman in a high pressure executive position may find it impossible to comply with her physician’s advice that she cut back on her work hours. Family members may refuse to acknowledge illness in a relative, or they may give advice that contradicts that of the physician.

• The patient may perceive that he or she benefits from being ill. He or she may get additional attention from family members, more time off work, or similar benefits. The patient may, on a conscious or unconscious level, wish to remain ill and therefore not comply.

• The patient may be noncompliant because of side effects from the medication. If the medication makes the patients feel worse, it is likely they will stop taking it.

There are undoubtedly other factors that contribute to poor compliance. A patient may let the physician know what these factors are if asked about them in a nonpunitive and nonjudgmental way. However, often physicians will need to ask repeatedly about compliance problems, especially those related to personal embarrassment or denial of illness.

Understand the close relationship between compliance and satisfaction and illness outcome

Factors That Enhance Compliance

• Good rapport with the physician. Patients who believe that their physician understands them and is interested in their welfare are far more likely to comply with the recommendations. It is also undoubtedly true that such a relationship will foster improved communication and greater mutual understanding. Shared priorities and styles of communicating enhance compliance.

• Simplifying treatment regimens. Patients will have a far easier time with once-a-day dosing whenever possible, fewer pills, and a regimen that is easy to remember, e.g., taking medications at bedtime (Porter, 1969).

• Clear and simple instructions. Physicians give directions regarding medication, but they do not always check to see what has been understood. Patients retain information better when it is presented at the beginning of a session rather than at the end (Ley, 1972). It is often useful to write down instructions if the patient can read, and to ask the patient to repeat the instructions. Misconceptions and misunderstandings can be readily cleared up if patients are asked to tell their physician what they understand about their illness and treatment regimen (Fuller and Gross, 1990).

• Positive feedback. Compliance improves when patients are encouraged and praised for the progress they are making.

• Increased level of subjective distress. Patients who feel bad tend to be compliant (Olson et al., 1985). Physicians can help patients understand the consequences of noncompliance by increasing their awareness of the disease and its impact by them.

• Decreased waiting room time. While many physicians say there is little they can do about how long patients wait, it is well worth the effort to look at ways to make an office more efficient from a patient ’s perspective. (Kaplan and Sadock, 1991)

• Increased time spent with the patient. Good time-management practices can increase the amount of time spent with patients.

• Family support and involvement.• Probably the single most important way to increase compliance is to identify the specific reasons why a particular

patient finds it difficult to adhere to treatment. A useful approach to fostering compliance is to examine factors systematically as they relate to the patient, the medical regimen, the spouse and family, and the doctor-patient relationship.