Beyond 'doctor's orders'
DOCTORS and nurses spend much of their working time discussing and
assessing patients’ healthcare problems and recommending actions which
will help restore or maintain health. On the basis of these
consultations, healthcare professionals (HCPs) may recommend taking
medication at set times, keeping clinic appointments, attending
physiotherapy, taking prescribed exercise or avoiding health-risk
behaviours such as unhealthy eating, unsafe sex or smoking. But
approximately 50 per cent of patients do not take prescribed treatments
as recommended and, across the various recommendations made by HCPs,
anything from 15 per cent to 93 per cent of patients do not act on
recommendations (Myers & Midence, 1998). Thus, despite the
expertise of HCPs, the accuracy of diagnoses and the effectiveness of
treatments, a substantial proportion of consultations have little or no
impact on patients’ health. Moreover, 10-25 per cent of hospital
admissions can be attributed to failures in following HCPs
recommendations or ‘non-adherence’.
Non-adherence is not confined to minor conditions. Studies in patients
who have received an organ transplant indicate that these patients are
just as likely to be non-adherent, even though non-adherence to the
medical regimen can lead to rejection of the organ and/or death of the
patient. For example, in a prospective study of heart, liver and kidney
transplants, 15 per cent of patients were considered non-adherent, with
30 per cent of non-adherent patients rejecting organs or dying compared
to 1 per cent of adherent patients (Rovelli et al., 1989). Moreover,
these levels of non-adherence are not new. Sackett and Snow (1979)
reported that ‘patients will keep approximately 75 per cent of the
appointments they make, but only about
50 per cent of those made for them… [and]…about [only] one-half of
patients on long-term regimens are compliant’ (p.95).
If HCPs changed their consultation styles to maximise adherence this
could have a substantial effect on the health of the nation and the
cost of providing healthcare services. Investigating how the behaviour
of HCPs affects non-adherence has been a core area of health psychology
research since the pioneering work of Philip Ley in the 1970s, and it
continues to be a focus for health psychology researchers. Findings
demonstrate that reduction of non-adherence depends upon understanding
the psychology of adherence and the social psychology of communication
between HCPs and their patients. In this article we review relevant
psychological research and discuss the practical implications for
behaviour change among HCPs. These include careful presentation of
information, using communication techniques that help patients remember
what have been said, managing interaction so as to maximise patient
satisfaction and tailoring communication to the beliefs, attitudes
and intentions of patients.
Why do we not follow advice?
Patients may be non-adherent for different reasons (Donovan &
Blake, 1992). For example, some patients intend to take recommended
actions but forget or find
it difficult to do so. Other patients may disagree with the doctor’s
diagnosis or the medication regimen and so decide not to take
medication (or to take more or less than was advised). Some key
questions that influence patients’ decisions to adhere, or not, are: Do
I really need this treatment? Am I at risk of symptoms if I do not
follow recommendation? How effective/beneficial is the recommended
action? What side-effects will it have? To what extent will adherence
conflict with other things I want to do? When consultations with HCPs
do not adequately answer these questions, patients may reach their own
conclusions and formulate a different plan to that recommended by a
HCP.
Presenting information and instructions
Oral information is poorly recalled. For example, in an early study,
patients had forgotten around half of the oral instructions given to
them after five minutes (Ley, 1973). Repeating advice can enhance
recall because patients may not take everything in on first hearing. In
addition, telling someone what you are about to tell them makes it more
likely they will remember because this assists encoding in memory. This
has been called ‘explicit categorisation’ (Ley, 1988). For example, a
doctor might say, ‘I’m going to tell you what I think is wrong with
you’ or ‘I’m going to remind you when you should take your tablets and
how many you should take’ before going on to provide important
information. Instructions may also be remembered more easily if the HCP
stresses that instructions are important and repeats them. Specific
advice, for example, ‘stop smoking’ or ‘make an appointment for two
weeks time’, is easier to remember than general suggestions such as
‘cut down the amount you smoke’ or ‘come in again soon’.
Provision of written information increases adherence. For example, one
review found an average increase in adherence of 60 per cent in groups
who were provided with additional written information (Ley, 1988). Such
improvement depends on the adequacy of written information. To be
useful, written information must be large enough to read and consist of
words that patients understand. Sadly, this is not always the case. For
example, in a national survey, Payne et al. (2002) examined 1038
leaflets distributed by UK palliative care units and found that 64 per
cent could be understood by only an estimated 40 per cent of the
British population.
Recently, Berry and colleagues conducted a series of experiments
investigating how information content and positive or negative
presentation affects satisfaction and adherence. In one study, members
of the general public were given explanations about medication based on
information found to be preferred by: (i) patients or (ii) doctors.
Both were presented in either a negative or positive manner. People
preferred the explanations based on what patients had wanted to know
about their medicines rather than what the doctors thought they should
be told. Inclusion of negative information reduced strength of
intention to adhere to the recommended medication regimen
(Berry et al., 1997) and presenting more personalised information (e.g.
using ‘you’ and ‘your’ whenever possible) was associated with increased
intention to adhere (e.g. Berry et al., 2003).
Research suggest that adherence will be greatest when HCPs listen to
what a patient wants to know about their medication and provide
information which answers the questions that patients typically want
answered. Although this seems obvious, much written information about
treatments and medication fails to achieve this (Coulter et al., 1999).
In addition, HCPs can encourage patients to take notes in consultations
and, when explaining how to undertake treatments, stress and categorise
important information, repeat it and personalise it. If HCPs follow
these evidence-based recommendations, their patients are more likely to
follow their healthcare recommendations.
Helping patients to remember and act on their intentions
When patients intend to adhere, successful adherence depends upon
recalling this intention at appropriate times and acting accordingly.
Such ‘prospective memory’ recall typically occurs some time after the
original instructions have been conveyed and may not be directly
prompted (e.g. by a reminder from someone else). Moreover, recall may
be required while the patient is engaged on other, often unrelated
activities.
Research into prospective memory has explored factors influencing
intention recall (Ellis, 1998). Results suggest event-based recall is
better than time-based recall. So trying to remember to ‘take
antibiotics (or do physiotherapy) twice a day’ is not likely to be as
effective as trying to remember to ‘take antibiotics before breakfast
and before dinner’. If multiple intentions have to be recalled, more
complex routine event sequences can be used, e.g. ‘take blue pill
before cereal and red pill with toast’. The need to link mediation to
routine events may be imposed by the effects of some medications. For
example, nonsteroidal anti-inflammatory drugs such as ibuprofen can
cause gastric irritation and it is recommended that they be taken with
or after food. The same approach to other treatments, including the
construction of individualised mnemonics that link treatment actions to
specific routine events and contexts, can reduce non-adherence.
Prospective memory can be a poorer amongst older people. A recent study
explored the relationship between prospective memory and medication
adherence in 42 older patients with tablet-controlled diabetes (Vedhara
et al., 2004). Patients who performed better on a computer task
designed to enhance prospective memory took significantly more correct
medication doses and made significantly fewer omission errors than
those who performed less well on this task, suggesting that efforts to
enhance prospective memory amongst older patients can improve adherence.
Studies of intentions and adherence using electronic monitoring devices
which record the date and time of an event (such as opening a
pill-bottle) have suggested another approach to improving adherence. By
examining data from individual patients it is possible to identify when
adherence failures occur. Patients can then be offered individualised
recommendations to improve medication recall at specific times of the
day (e.g. when brushing one’s teeth or at a mealtime). They can also be
advised to leave medication in a prominent position associated with a
routine event (e.g. beside the bed or in the refrigerator). This
approach has been called ‘cue-dose’ training and has had some success
in reducing non-adherence in relation to blood glucose control in
diabetes, nebuliser use in people with obstructive lung disease and
taking medication, including psychiatric, antiretroviral and
anti-diabetic medication (e.g. Rosen et al., 2004)
Similarly, making plans that specify where and when intentions are to
be acted on has been shown to increase the likelihood of action.
Gollwitzer (1999) has called such specific plans ‘implementation
intentions’. For example, resolving to take one’s medication in the
bathroom, immediately after a morning shower makes enactment more
likely than just resolving to take medication. Without forming such an
implementation intention, a genuine intention may be postponed and then
forgotten in the midst of other morning priorities, whereas an
implementation intention can prompt taking medication as soon as the
person steps out of the shower. Implementation intention formation has
been shown to have this effect for a variety of health-related
behaviours such as breast self examination, taking vitamins, attending
screening and rehabilitation after surgery (Sheeran, 2002).
From ‘doctor’s orders’ to concordance
Early research in this area used the term ‘non-compliant’,
reflecting a view that patients should do what they are told by HCPs
and that failing to do so was patients’ own responsibility.
Psychologists (and other social scientists) have clarified that
patients may not follow advice because they do not remember it, do not
understand it or do not know how to follow it. The term ‘adherence’ is
now preferred because it suggests a collaborative involvement of HCPs
with their patients in which they work together to plan and implement
treatments. The need for such co-operation has been emphasised more
recently by the suggestion that HCPs and patients should reach
‘concordance’ in consultations – a mutual understanding and agreement
about treatment and its implementation (Mullen, 1997).
Communication between HCPs and patients is critical to adherence. A
recent review demonstrated that doctor–patient interaction influences
treatment adherence (Di Matteo, 2003) and other studies have found that
GP–patient communication style (e.g. Bultman & Svarstad, 2000) and
the pharmacist–patient relationship influences patient adherence (e.g.
Worely-Louis et al, 2003).
Fortunately, considerable work has been undertaken on identifying key
communication skills needed in consultations and on developing
effective communication skills training programmes (e.g. Maguire &
Pitceathly, 2002; Simpson et al., 1991) so it is possible to train HCPs
to use satisfaction-inducing communication styles in consultations.
This is key because patient satisfaction with HCPs, and consultations
with HCPs, is significantly correlated with adherence (Ley, 1988). If a
patient feels their doctor is not interested in their problem, or has
not understood it, this will undermine confidence in the doctor’s
advice. For example, in a seminal study of paediatric consultations,
Korsch et al. (1968) found that mothers who were very satisfied with
their doctor’s warmth, concern and communication were three times more
likely to adhere than dissatisfied mothers.
Satisfaction depends upon the patient’s perception of the doctor’s
sensitivity, concern, respect and competence. Reducing waiting time,
taking time to greet the patient in a courteous manner
and engaging in friendly introductory exchanges are all likely to
increase satisfaction. Asking open-ended questions which cannot be
answered ‘yes’ or ‘no’ and allowing the patient time to express their
worries, without interruption, is also likely to enhance patient
satisfaction. This may require restraint on the part of HCPs who may
feel under time pressure to develop a clear action plan and move on to
the next patient (e.g. Simpson et al., 1991) but if such restraint
increased adherence it would be a good investment of professional time.
Tailoring communication to the patient’s beliefs
A variety of models have been used to identify specific beliefs and
cognitions associated with health-related behaviour, including
treatment adherence (for example see Conner & Norman, 1996). Models
such as the theory of planned behaviour (Ajzen, 1991), the health
belief model (Rosenstock, 1974) and social cognitive theory, including
self-efficacy (Bandura, 1977; 1997) provide useful and parsimonious
accounts of the psychological antecedents of behaviour. For example the
TPB has been found to explain between 23 per cent and 34 per cent of
the variance in measures of behaviour across reviews (Ajzen, 1991;
Armitage & Conner, 2001).
Applications of such models to adherence have been encouraging. For
example, a study of adherence to prophylactic antimalarials found that
in addition to the cognitions specified by the theory of planned
behaviour, perceived side- effects were an important predictor of
adherence on return from a malarious region. It was also found that
that perceived susceptibility to malaria infection and perceived
severity of symptoms (cognitions specified by the health belief model)
contributed to strength of intentions to take the medication as
directed (Abraham et al., 1999). Thus good information on
susceptibility to malaria and side-effects, from either GPs or
community pharmacists, may be crucial to adherence rates for this
treatment.
Such models specify a series of cognitions that affect whether or not a
person follows treatment recommendations. These include beliefs about
consequences of the action. For example, ‘the treatment will only
effectively prevent further illness if I take it as directed’, ‘the
treatment has serious side-effects’, ‘the illness is life-threatening
if not treated’. Others’ approval is also a potentially important
consequence. For example, ‘my partner thinks I should take my
medication and my partner’s approval is important to me’. If a patient
has doubts about the effectiveness of a recommended treatment, believes
it will be difficult or unpleasant or thinks it is socially
unacceptable, they are unlikely to formulate stable intentions to
adhere to the recommended treatment regimen. By allaying fears about
side-effects or social desirability and/or emphasising the
effectiveness of the treatment and the threat posed by the illness,
HCPs can promote concordance. This may be enhanced by prompting
patients to express their treatment intentions (e.g. ‘Yes, I will stop
smoking this Friday’) and even sign contracts. This can bolster
commitment, especially in relation to actions to be undertaken at
particular times and places.
Self-efficacy, that is, the belief that one can successfully take
specified actions, has been found predict action (Bandura, 1997). For
example, in a study of adolescents and young adults with Type 1
diabetes, self-efficacy and personal control beliefs explained 39 per
cent of self-reported adherence (including insulin injections, diet,
exercise, and blood glucose measurement) (Griva et al., 2000).
Encouraging patients to break down complex tasks (such as taking
exercise or changing diet) into to easier steps, to monitor and record
their actions and to focus on past successes can all help enhance
treatment self-efficacy. Self-efficacy can also be developed by
discussing how patients will manage treatment in practice, by
considering difficulties patients foresee and developing plans to over
come these. For example, helping people plan how they will acquire
recommended foods or nicotine patches, how they will join a smoking
cessation group, how they will talk to others about changing their
habits or how they will renew commitment to behaviour change (even
after failures) are all likely to enhance feelings of control over the
recommended treatment actions.
Patients can also benefit from discussing treatment with other patients
and learning new ways to manage difficult aspects of treatment. The
Chronic Disease Self-Management Programme involves patient group
meetings covering topics such as relaxation, symptom management,
exercise, fatigue and interaction with healthcare professionals. The
programme has been found to improve a range of health outcomes; for
example, a five-year randomised control trial found that participants
increased health behaviours, such as exercise, had more satisfactory
interactions with doctors and less disability (British Liver Trust,
1999). Similarly, evaluations of the patient-led Arthritis
Self-Management Programme has been found to enhance self-efficacy and
health behaviours, including exercise (Lorig et al., 1986).
Such programmes provided models for the Expert Patient Programme (EPP)
now being implemented by many primary care trusts in the UK. EPP
consists of patient-led groups run over six consecutive weeks for about
12 patients. Topics include diet, exercise, communication and use of
medication. Evaluations of the EPP are ongoing but it seems likely that
such self-management interventions could help patients to act in
accordance with HCPs’ recommendations.
Conclusion
Research into psychology of non-adherence has identified a series of
factors which determine whether or not patients’ act on the advice of
healthcare professionals. Many of these factors can be modified through
the consultation management or communication style of healthcare
professionals. Health psychologists can review this evidence and then
make evidence-based recommendations for modifications to consultation
management, professional training and preventive healthcare services.
The challenge is to change the routine behaviour of healthcare
professionals in order to change the health behaviour of their patients.
- Dr Lynn Myers is at the Centre for Behavioural and Social Sciences in
Medicine at University College London. E-mail: [email protected].
- Professor Charles Abraham is at the University of Sussex. E-mail: [email protected].
Weblinks
Medicines Partnership: www.concordance.org
Royal Pharmaceutical Society of Great Britain: www.rpsgb.org.uk/index.html
Discuss and debate
Are there any other ways that psychologists may influence consultations?
How effective can changing consultations be in changing people’s adherence?
Are there some illnesses where effective consultations are more relevant than others?
Have your say on these or other issues this article raises. Send
letters to [email protected] or contribute to our forum via
www.thepsychologist.org.uk.
References
Abraham, C., Clift, S. & Grabowski, P. (1999). Cognitive
predictors of adherence to malaria prophylaxis regimens on return from
a malarious region. Social Science and Medicine, 48, 1641–1654.
Ajzen, I. (1991). The theory of planned behaviour. Organizational Behavior and Human Decision Processes, 50, 179–211.
Armitage, C.J. & Conner, M. (2001). Efficacy of the theory of
planned behaviour: A meta-analytic review. British Journal of Social
Psychology, 40, 471–495.
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191–215.
Bandura, A. (1997). Self-efficacy: The exercise of control, New York: Freeman.
Berry, D.C., Michas, I.C. & Bersellini, E. (2003). Communicating
information about medication: The benefits of making it personal.
Psychology and Health, 18, 127–139.
Berry, D.C., Michas, I.C., Gillie, T. & Forster, M. (1997). What to
patients want to know about their medicines and what do doctors want to
tell them? Psychology and Health, 12, 467–480.
British Liver Trust (1999). Living a healthy life with long term
illness: Leaders manual. The Board of Trustees, Leyland Stanford Junior
University.
Bultman, D.C. & Svarstad, B.L. (2000). Effects of physician
communication style on client medication beliefs and adherence with
antidepressant medication. Patient Education and Counseling, 40,
173–185.
Conner, M. & Norman, P. (Eds.) (1996). Predicting health behaviour:
Research and practice with social cognition models. Buckingham: Open
University Press.
Coulter, A., Entwistle, V. & Gilbert, D. (1999). Sharing decisions
with patients: Is the information good enough? British Medical Journal,
318, 318–322.
Di Matteo, R. (2003). Future directions in research on
consumer–provider communication and adherence in cancer prevention and
treatment. Patient Education and Counseling, 50, 23–26.
Donovan, J.L. & Blake, D.R. (1992). Patient non-compliance:
Deviance or reasoned decision-making. Social Science and Medicine, 34,
507–513.
Ellis, J. (1998). Prospective memory and medicine-taking. In L.B. Myers
& K. Midence (Eds.) Adherence to treatment in medical conditions.
London: Harwood Academic.
Gollwitzer, P.M. (1999). Implementation intentions: Strong effects of simple plans. American Psychologist, 54, 493–503.
Griva, K., Myers, L.B. & Newman, S.N. (2000). Illness perceptions
and self-efficacy beliefs in adolescents and young adults with insulin
dependent diabetes mellitus. Psychology and Health, 15, 733–750.
Korsch, B.M., Gozzi, E.K. & Francis, V. (1968). Gaps in doctor–patient communication, Pediatrics, 42, 855–871.
Ley, P. (1973). Communication in the clinical setting. British Journal of Orthodontics 1, 173–177.
Ley, P. (1988). Communicating with the patient. London: Croom Helm.
Lorig, K., Feigenbaum, P., Regan, C. et al. (1986). A comparison of
lay-taught and professional-taught arthritis self-management courses.
Journal of Rheumatology, 13, 763–767.
Maguire, P. & Pitceathly, C. (2002). Key communication skills and
how to acquire them. British Medical Journal, 325, 697–700.
Mullen, P.D. (1997). Compliance becomes concordance. British Medical Journal, 314, 691–692.
Myers, L.B. & Midence, K. (Eds.) (1998). Adherence to treatment in medical conditions. London: Harwood Academic.
O’Dowd, T.C. (1988). Five years of heartsink patients in general practice. British Medical Journal 297, 528–530.
Payne, S., Large, S., Jarrett, N. & Turner, P. (2000). Written
information given to patients and families by palliative care units: A
national survey. The Lancet, 355, 1792.
Rosen, M.I., Rigsby, M.O., Salahi, J.T. Ryan, E. & Cramer, J.A.
(2004). Electronic monitoring and counseling to improve medication
adherence. Behaviour Research and Therapy, 42, 409–422.
Rosenstock, I. (1974). The health belief model and preventative behaviour. Health Education Monographs 2, 354–386.
Rovelli, .M., Palmeri, D., Vossler, E. et al. (1989). Compliance in
organ transplant recipients. Transplantation Proceedings 21, 833–844.
Sackett, D.L. & Snow, J.C. (1979). The magnitude of compliance and
noncompliance. In R.B. Haynes, D.W. Taylor & D.L. Sackett (Eds.)
Compliance in health care. Baltimore, MD: Johns Hopkins University
Press.
Sheeran, P. (2002). Intention–behavior relations: A conceptual and
empirical review. In W. Stroebe & M. Hewstone (Eds.) European
review of social psychology (Vol. 12, pp.1–36). Chichester: Wiley.
Simpson, M., Buckman, R., Stewart, M. et al. (1991) Doctor–patient
communication: The Toronto consensus statement, British Medical
Journal, 303, 1385–1387.
Vedhara, K., Wadsworth, E., Norman, P. et al. (2004). Habitual
prospective memory in elderly patients with Type 2 diabetes:
Implications for medication adherence. Psychology, Health and Medicine,
9, 17–27.
Worely-Louis, M.M., Schommer, J.C. & Finnegan, J.R. (2003).
Construct identification and measure developments investigating
pharmacist–patient relationships. Patient Education and Counseling, 51,
229–238.
(Please note that some pictures may have been removed for copyright reasons)
BPS Members can discuss this article
Already a member? Or Create an account
Not a member? Find out about becoming a member or subscriber