Long-term chronic diseases have a high mortality rate, accounting for 60% of all deaths worldwide.[1] However, according to the World Health Organisation (WHO), approximately 50% of the patients with chronic illnesses don’t follow treatment recommendations[2].  Low compliance rates have been demonstrated in the treatment of a range of chronic illnesses including psychiatric disorders (50%)[3], depression (13% to 52%)[4]; diabetes (less than 50%: 25% to 65% for diet and 20% for insulin administration)[5]; hypertension (50%)[6]; bronchial asthma (50%)[7]; Fibromyalgia (47%)[8]; Inflammatory Bowel Disease (33%)[9];  obesity (61%)[10], as well as reportedly low rates for autoimmune rheumatic diseases[11], anxiety disorders[12] and Parkinson’s Disease[13].

There are a number of ways that lack of treatment adherence is demonstrated in patients with chronic illness including not complying with medication, diet, clinic attendance, or changes in lifestyle. This is an obstacle to improving patients’ health and quality of life. Interestingly, non-compliance has been shown to be uncommon in acute illness, indicating the factors leading to non-compliance are related to aspects of long-term care. In particular, there are “hard” factors and “soft” factors that contribute to a person’s level of compliance. Hard factors are quantifiable and may be adaptable to counselling and effective communication by healthcare providers. They include…

  • Therapy-related factors such as treatment complexity, duration of treatment, medication side effects.
  • Social and economic factors such as the ongoing cost of therapy
  • Accessibility and satisfaction with healthcare facilities
  • Disease factors such as symptoms or severity

“Soft” factors, on the other hand are patient-centred including a patient’s beliefs, attitude towards therapy and their motivation levels. Unlike “hard” factors, “soft” factors are much more difficult to measure and offset. For instance, patients may have incorrect beliefs due to inadequate knowledge about the purpose of therapy and the consequences of non-compliance, or they may have a negative relationship with their healthcare provider. Conversely, a patient’s compliance may be enhanced by a healthy relationship and effective communication with their healthcare provider[14].

It’s important that “soft” factors are addressed as they may negate the efforts spent countering the effects of the “hard” factors on compliance. So, why do people comply with treatment or do not? Some psychological theories attempt to explain this.

The Health Belief Model[15] refers to people’s beliefs about treatmen. It suggests that a person will take a health-related action (i.e., use condoms) if they feel a negative health condition (i.e., HIV) can be avoided; if they have a positive expectation that by taking a recommended action, they will avoid a negative health condition (i.e., using condoms will be effective at preventing HIV); and if they believe they can successfully take a recommended health action (i.e., use condoms comfortably and with confidence).

The Theory of Reasoned Action[16] focuses on people’s attitudes. It suggests that behavioural intentions are influenced by an individual’s attitude about the likelihood that the behaviour will have the expected outcome and what they perceive to be the risks and benefits of that outcome.

The Self-Determination Theory (SDT)[17] is a theory of motivation. It suggests there are two basic types of motivation: extrinsic and intrinsic. Extrinsic motivation is where a person tends to do a task or activity mainly because doing so will yield a reward or benefit. Intrinsic motivation, in contrast, is characterised by doing something purely for enjoyment or fun.

A person’s beliefs, attitudes and motivation levels impact their readiness and willingness to engage in treatment and at what stage of change they are. The Transtheoretical Model of Change (TTM)[18] suggests that individuals move through six stages of change: from precontemplation where a person does not intend to take action in the foreseeable future, through to contemplation, preparation and then action, where a person has changed their behaviour and intends to continue with that behaviour change. Health professionals can assist their patients change their behaviour and move through the stages by using different intervention strategies at each stage to move them to the next stage of change.

So, what specifically can health professionals do to help their patient’s increase their willingness and readiness to comply with treatment recommendations?

  1. Clarify a patient’s knowledge & understanding of their illness and highlight the negative consequences of not engaging in treatment with regard to the progression of their illness.

2. Identify a person’s stage of change by asking specific questions about how problematic they view their current behaviour or when they intend to change.

3. Normalise the process of change and utilise targeted strategies to help move the person to the next stage of change. It’s important not to assume that all patients are in the action stage, as the majority of patients who present for treatment tend to be in the pre-contemplation or contemplation stages. Using action strategies in these stages may actually lead to further non-compliance and drop outs.

4. Prioritise treatment goals and help patients establish ‘approach’ goals rather than ‘avoidance’ goals. Approach goals involve moving towards and reaching desired outcomes and they are pleasurable and exciting whereas avoidance goals focus on avoiding or eliminating undesired outcomes and they can be stressful and anxiety provoking. Pursuit of approach goals are associated with more satisfaction with progress while pursuit of avoidance goals are related to more negative feelings about progress, including decreased self-esteem, personal control and competence. For instance, setting outcome goals for weight loss around feeling fitter or having more energy for obesity patients rather than goals about reducing their chances of mortality or having a heart attack, will be more motivating.

5.Highlight the importance, attractiveness and benefits of changing behaviour, and link it to their values, as this may reduce their ambivalence and increase their motivation, confidence, and commitment to taking action. Patients in pre-contemplation or contemplation can be resistant and defensive about changing behaviour as they underestimate the pros of change and place too much emphasis on the cons of change. Continue to roll with a patient’s resistance while increasing their perception of the enablers of change and the barriers or blocks to change.

6. Normalising relapse and minimising a patient’s shame about relapse needs to be included in treatment. Progression through the stages is not linear and patients may recycle several times before achieving maintenance and sustained behaviour change.

7. Match the appropriate strategies to the correct stage of change. For example, a person who is in pre-contemplation does not currently perceive their behaviour as problematic, so consciousness raising may be beneficial to move them to contemplation stage. This may involve increasing their awareness about healthy behaviours through education, information, observations, and feedback. For people in contemplation, using self-reflection and self-appraisal to realise that the healthy behaviour is part of who they want to be may help them progress to preparation. This may involve values clarification or imagery. For someone in preparation, self-liberation strategies such as committing to change their behaviour, both privately and publicly, may help move them to action. However, avoid mismatching strategies and stages; for instance, using action-oriented strategies may be detrimental in pre-contemplation or contemplation stages as awareness and insight is a prerequisite to change.

References

1 Rafii, F., Fatemi, N. S., Danielson, E., Johansson, C. M., and Modanloo, M. (2004). Compliance to treatment in patients with chronic illness: A concept exploration. Iran Journal of Nursing Midwifery Research, 19(2): 159–167.

2 WHO (2003). Adherence to Long-Term Therapies, Evidence for action, full report.

3 Andrade, L. H. et al (2014). Barriers to Mental Health Treatment: Results from the WHO World Mental Health (WMH) Surveys. Psychol Med, 44(6): 1303–1317.

4 Stein-Shvachman, I., Karpas, D., & Werner, P (2013). Depression Treatment Non-adherence and its Psychosocial Predictors: Differences between Young and Older Adults? Aging and Disease, 4(6); 329-336.

5 Luis-Emilio Garcı´a-Pe´rez, L., A´ lvarez, M., Dilla, T., Gil-Guille´n, V., Orozco-Beltra´n, D. (2013). Adherence to Therapies in Patients with Type 2 Diabetes. Diabetes Therapy, 4:175–194

6 Vrijens, B., Antoniou, S., Burnier, M., de la Sierra, A. Volpe, M (2017). Current Situation of Medication Adherence in Hypertension. Frontiers in Pharmacology, 8 Article 100.

7 Eakin, M. & Rand, C. (2012). Improving Patient Adherence with Asthma Self-Management Practices: What Works? Ann Allergy Asthma Immunol, 109(2): 90–92.

 8 Sewitch, M., Dobkin. P.Bernatsky, S., Baron, M., Starr, M., Cohen, A., & Fitzcharles, A. (2004). Medication non-adherence in women with Fibromyalgia, Rheumatology, 43:648–654.

9 Ghadir, M., Bagheri, M., Vahedi, H., Ebrahimi Daryani, N., Malekzadeh, R., Hormati, A., Kolahdoozan, S., & Chaharmahali, M. (2016). Nonadherence to Medication in Inflammatory Bowel Disease: Rate and Reasons. Middle East J Dig Dis: 8:116-121.

10 Kuzmar, I., Rizo, M, & Cort´es-Castell, E. (2014). Adherence to an overweight and obesity treatment: how to motivate a patient? PeerJ 2: e495.

11 Anghel, L., Farcaş, A., & Oprean, R. (2018). Medication adherence and persistence in patients with autoimmune rheumatic diseases: a narrative review. Patient Preference and Adherence, 12: 1151–1166.

12 Santana, L. & Fontenelle, L. F. (2011). A review of studies concerning treatment adherence of patients with anxiety disorders. Patient Preference and Adherence, 5: 427–439.

13 Fleisher, J. & Stern, M. (2013). Medication Non-adherence in Parkinson’s Disease. Curr Neurol Neurosci Rep, 13(10).

14 Jin, J., Sklar, G., Min Sen Oh, V. & Chuen, S. (2008). Factors affecting therapeutic compliance: A review from the patient’s perspective. Therapeutics and Clinical Risk Management,4(1): 269–286.

15 Rosenstock, I. (1974). Historical Origins of the Health Belief Model. Health Education Monographs, 2:4.

16 Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior. Reading, MA: Addison-Wesley.

17 Deci, E. L., & Ryan, R. M. (1985). Intrinsic motivation and self-determination in human behavior. New York, NY: Plenum.

18 Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research & Practice, 19(3), 276-288.