Health Psychology on Compliance & Adherence

Compliance, Adherence, and Concordance

• Compliance refers to the extent a patient follows medical advice, emphasizing a doctor-centered approach where the patient is passive.
• Adherence focuses on the alignment between patient behavior and medical recommendations, promoting a patient-centered model with mutual agreement.

Extent of Non-Adherence

• Non-adherence is common, especially among chronic illness patients, with estimates of 30-50% non-adherence rates.
• Approximately 10-25% of hospital admissions are due to non-adherence.
• Review of 733 studies over 50 years reveals an average non-adherence rate of 24.8%.
• Lifestyle changes often show particularly low adherence rates.

Disease-Specific Non-Adherence

• Severe diseases, including organ transplant recipients, show significant non-adherence, with 22% of renal transplant patients failing to take immunosuppressants.
• Non-adherence leads to higher rates of organ rejection or death.
• HIV, arthritis, GI disorders, and cancer show the highest adherence rates; pulmonary disease, diabetes, and sleep disorders have the lowest.

Impact of Non-Adherence

• Non-adherence negatively affects patient health and incurs financial costs.
• Enhancing adherence interventions may yield greater health benefits than improvements in medical treatments.

Measuring Adherence

• Treatment typically involves ongoing adherence, making measurement challenging.
• Variability in adherence measures complicates comparisons across different studies and conditions.

Indirect Measures of Adherence

• Patient self-reporting is easy and inexpensive but often inaccurate, with reported compliance at 78%, contrasted with objective measures around 46%.
• Second-hand reports from healthcare providers reflect similar issues.
• Pill counts provide a more objective measure but can still be inaccurate due to lost pills.
• Mechanical or electronic dosage reminders can measure dispensing but not actual consumption.

Direct Measures of Adherence

• Biological tests (urine or blood) offer direct adherence measures but are invasive, costly, and affected by metabolic factors.
• Observational methods mimic the challenges present in biological measures.

Barriers to Adherence

• Common barriers include high treatment costs, lack of information, and potential side effects.
• Patient satisfaction during consultations strongly correlates with adherence rates.

Ley’s Cognitive Hypothesis Model

• Patients' understanding, memory, and satisfaction impact compliance.
• Satisfaction derives from emotional support, perceived competence, and correctness of diagnosis.

Patient Understanding and Recall

• Many patients struggle with recalling medical information accurately—only a fraction can define illnesses or remember treatment specifics.
• Recall is influenced by anxiety, prior knowledge, and modality of information presented.

Improving Compliance

• Effective communication is essential, involving simplified information, repetition, and clear written instructions.
• Follow-up consultations help reinforce understanding and adherence.

Criticisms of Ley’s Model

• Limits of information correction and treatment preparation highlight the need for a broader view of adherence factors.

Treatment Factors & Adherence

• Poor supervision, continuity of care, and treatment characteristics (complexity, inconvenience, expense) can hinder adherence.

Doctor-Patient Interaction

• Warm, caring physician behaviors improve patient adherence.
• Interpersonal and technical competence, as well as positive body language, increase patient compliance.

Health Belief Model

• Cognitive model explains adherence based on patients' beliefs about disease and treatment benefits.
• Adherence depends on perceived disease severity, susceptibility, treatment benefits, and barriers.

Patients’ Beliefs

• Patient understanding of illness severity and medication risks influences adherence levels.
• Positive patient relationships with healthcare providers facilitate trust and adherence.

Steps Towards Concordance in Prescribing

• Clarifying problems by integrating patient input, conveying treatment options, and ensuring understanding fosters concordance.
• Encourage patient feedback on care decisions to tailor treatments to individual needs.

Concordance Tensions

• Navigating the balance between evidence-based medicine and patient autonomy is crucial for fostering adherence.
• Addressing potential conflicts between patient rights and responsibilities enhances concordance.

Summary Points

• Key factors affecting adherence include memory, understanding, satisfaction, doctor-patient communication, and social context.
• Barriers can stem from treatment complexity, perceived stigma, or socio-economic factors that influence adherence levels.