First, it’s essential to distinguish between compliance and adherence. The available literature often confounds them, even though they both describe a gap between prescribed behavior and actual behavior.
I would propose that noncompliance is best defined as gaps that occur for unintentional reasons (or factors beyond the patient’s control), while nonadherence is best defined as gaps that occur because of unilateral and intentional decisions to alter therapy.
Looking through this lens, we see that the same behaviors can come from remarkably different causes, and so a “one-size-fits-all” approach just won’t work. Considering intent also provides clues on how to consult patients to determine what’s really going on when they fall “out of compliance.”
Here are 3 questions that may prove useful to ponder.
1. How well does the patient understand the critical information?
Informing a patient about a topic and being assured that the information was learned are 2 different issues. Good training programs assess learning afterwards.
Of course, we don’t want to give patients a test, but how else can we know that they’ve got it? One idea involves asking a compliance-related hypothetical question that requires the patient to describe what they’d do.
For example, we might ask how to handle a missed dose, or what to do if they felt a certain way after taking the medication. Answers could be quickly scored and areas of improvement could be identified.
2. What “compliance landmines” exist?
Medication regimens require a fundamental modification of the patient’s daily life. Although changes are minor in most cases, being forced to adapt is never easy.
The pharmacist can help by providing a safe space for patients to react. In organizational science, we call this “managing the change process.”
Change can create both negative and positive effects such as stress, anxiety, self-doubt, excitement, and anticipation. These reactions can act as landmines in destroying motivation for medication adherence. The larger the change, the more powerful the effects can be.
For example, a new insulin-dependent patient with diabetes may have a fear of needles, the busy patient may find managing several medications irritating, or the man who has never cared much about being punctual may have difficulty with carefully timed doses. Medications may also remind a person of his or her illness, which is something that they’d rather deny.
The pharmacist can potentially help by simply making the patient aware of these “compliance landmines.”
3. How does the patient value the treatment?
Patients make decisions based on how they value the options that they have.
Imagine that you pay $12 to see a movie with a friend. Twenty minutes into the show, the movie seems very bad and you consider leaving, but you’ve already spent another $10 on refreshments. What do you do now?
In this instance, you have at least 2 choices: leave the theater or stay and finish the movie.
While leaving would spare you from watching more of a bad movie, your friend might be enjoying the show. You’ve also made a financial investment in the evening that would go for naught. On the other hand, if you stay and finish the movie, you can avoid any uncomfortable interactions with your friend and justify the money that you’ve spent, but you must suffer through another 90 minutes of a bad movie, which is time you could’ve used more effectively.
In this scenario, your decision is based on your unique experiences and values. Whether the decision was a good one depends not only on what happens next, but also how you value those consequences.
In other words, our behavior is usually justified retrospectively. If you stay and finish the movie, you may justify that decision by believing that $20 was too much to pay for 30 minutes of a movie, or you may argue that the time spent with your friend was more valuable than the discomfort you experienced from viewing a bad movie.
What if nonadherence works the same way? A patient may choose to alter therapy because nonadherence is the best “behavioral value” at the time, meaning the benefits simply outweigh the costs. To exacerbate the issue, the perceived benefits of nonadherence are usually immediate and short-term, but the costs are delayed and long-term.
In other words, patients are likely to reap the rewards first and then suffer the consequences later. Considering a patient’s decisions from the standpoint of behavioral economics can illuminate factors that contribute to unwise adherence choices.
Because time and opportunity to counsel patients may be scarce, here are some tips for quickly speaking with patients about their medications.
- Ask open-ended questions to determine what the patient understood about the consequences of “medication misbehavior.” Don’t ask: “You know what will happen if you don’t take this medication correctly, right?” Instead, ask: “What may happen to you if you don’t take this medication correctly?”
- Let the patient imagine what life would be like if his or her medication regimen wasn’t necessary. The point is to gain insight into factors that could derail the patient’s good intentions and intervene early to prevent nonadherence. Be prepared to discuss these factors with the patient to head off any potential problems.
- Let the patient be the expert. Let patients have the chance to tell you how they’re structure their care if the power were in their hands. This tactic can be useful if a patient is well-educated in health issues and may choose to “overrule” the medication instructions. It also encourages the patient to feel like part of the solution rather than the problem.
- Consider a cost-benefit inventory. This could be designed as a brief survey instrument where patients list negative factors (costs) and positive factors (benefits) associated with their therapy. Encourage patients to be thorough and not self-censor. Doing so will help you learn more about patients’ viewpoints, as well as help patients become more self-aware.
If the pharmacy field wants to impact adherence, its practitioners must embrace the clinical role and facilitate knowledge, understanding, and “valuing” of health among patients.
Kraig Schell, PhD
Kraig Schell, PhD, is a Professor of Psychology and Director of the Consultation and Research Institute at Angelo State University in Texas, and also Affiliate Professor of Pharmaceutical Outcomes and Policy at the University of Florida School of Pharmacy. He has taught, consulted, and authored dozens of continuing education articles for pharmacists on patient safety and engagement, as well as the application of psychological principles to safer and more effective care.