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Facilitating Adherence to
..... : .... :...
Treatment Regimens

Shirley P. Darnrosch

Habit is habit, not to be flung out of the window but
rather coaxed downstairs, one step at a time.'
..
The unfortunate thing about the world is that good
habits . are much . easier
.'
to give up than bad ones
. .
..
,',',.
SOMER5ET MAUGHA.Yi
Problems of poor adherence permeate all elinical aspects
of health careo Adherence is problematic for both preven-
tive regimens and the self-management of treatment regi-
mens for patients with acute and chronic disease.
Adherence can be defined as the extent to which patients
follow their provider's health care recommendations. The
older ter m compliance is frequently used, essentially as a
synonym for adherence. Currently, however, many a 11 thors
prefer to use adherence, beca use this word is viewed as con-
noting a more mutual invo/vement between patient and pro-
vider. Compliance, on the other hand, is seen as implying a
relationship between authoritattve provider and a relative/y
passive patient.
OPERATIONALLY DEFINING
ADHERENCE
Self-Reports
Self-reports by patients are probably the most widely used
,', ','::'.;
operationalization of adherence. However, the drawbacks
of this approach are well documented. For example, the '
patient may give a "socially acceptable" but false version of
adherence to avoid self-embarrassment or upsetting the
provider. The tendency to respond in a socially desirable
way is a basic weakness of self-reports; the tendency is es-
pecially problematic with sensitive .topics (e. g., extent of
alcohol or illicit drug consumption). Moreover, even con-
scientious patients can make honest mistakes in recollec-
tion,
A good provider or researcher realizes that self-reports
are more likely to be honest if patients are queried under
conditions where mutual trust, nonjudgmental under-
standing, and absence of stress prevail. In any event, phy-
sicians should validate self-reports whenever this is feasi-
ble.
Collateral Reparts
Collateral reports of adherence inelude feedback from the
patient's various health care providers, friends, or family
members. For example, the pharmacist may report faiJure
to renew a prescription. Accuracy of such feedback of
course depends on the reporter's familiarity with the pa-
tient and willingness to act as a whistle blower if adherence
IS poor.

The simple definition of adherence just given will not suf-

fice for providers or researchers who wish to rneasure de-
gree of adherence. For such purposes, an operational def-
inition is necessary; that is, the definition must specify the Keep watch also on the faults ofpatients, which make
method or methods (or operations) used to measure ad- them líe about the taking of things prescribed,
herence. Major types of operational definitions used by
providers or researchers inelude (1) self-reports, (2) collat- HJpPOCRATES (circa 400 Be)
eral reports, and (3) objective measures.
306 Part 5: Making Decisions About Patients
. If the physician observes no improvement despite ap-
propriate medication, this may indica te nonadherence. It
is important for physicians to realize that they may some-
times be the last to know about poor adherence. Research
has consistently shown that physicians tend to overestimate
tneir OlVl1 patients' degree of adlzerence; physicians also tend
to be poor at distinguishing their adhering from their nonad-
hering patients.
Objective Measures
Objective measures of adherence inelude such factors as
pill counts (i. e., amount of medicine left in the bottle),
records of appointment keeping, physical testing to assay
presence of prescribed drug or absence of forbidden drug,
and rneasures of cholesterol to check on diet adherence.
Ingenious devices are continually being added to the list of
objective ways to measure adherence. For example, a spe-
cial medication bottle cap fitted with an electronic monitor
is available to record date and time on a microprocessor
chip each time the bottle is opened.
Objective measures also have a number of limitations.
First, they may be costly and cumbersome. Second, they
may in sorne cases foster an adversarial climate between the
patient and provider. For exarnple, sensitive patients may
feel the provider regards their reports as untrustworthy;
sorne patients may even feel challenged to deceive the eval-
uator by, for example, emptying the pill container, knowing
a pill count wil! be made.
Selj-Report vs. Objective Means
Research has consistently shown that adherence reparts are
/ess accurate when measured by seit-reports rather than ob-
jective means. For exarnple, researchers recently compared
adherence in 350 patients with rheumatoid arthritis by self-
reports and by using electronically monitored bottle caps
for each patient. The research team was careful to encour-
age candid reporting by patients, stressing the confidenti-
ality of the self-reports and promoting a cooperative staff-
patient relationship. Nevertheless, among the 350 patients,
only 7% met the criteria for poor adherence in terms of
self-reports, whereas 53% did so by use of the electronic
monitor.
Self-reports may be especially vulnerable when rneasur-
ing alcohol and illicit drug usage. A drama tic exarnple was
recently provided by samples of homeless men residing in
large New York City shelters. In self-reports, admitted cur-
rent drug or alcohol usage was less than 20%; however,
urinalysis was positive for drugs or alcohol in 80% of these
meno
]UST WHAT THE PATIENT ORDERED
In 1997, the Food and Drug Administration (FDA) relaxed
its rules to make it easier for pharmaceutical companies to
advertise their prescription products directly to patients vía
television; magazines and other popular media are also
outlets for these paid messages. The companies budgeted
almost $600 million for direct-to-patient ads in 1996; these
expenditures are projected to grow dramatically in the
rwenty-first century.
Such advertising is ubiquitous. For example, several re-
cent issues of People, a gossip magazine with a circulation
of over 3 mil!ion, carried two pages of side-by-side adver-
tising for Prozac. The left-hand page proelaimed "Depres
sion hurts" against a black background featuring a cloud
and raindrops. In contrast, the right-hand page superim-
posed the message "Prozac helps" on a bright blue back-
ground with a blazing yellow sun. The drug companies
are banking on advertising like this to cultivate brand
awareness, so patients will ask doctors for a prescription
by narne, presumably influencing their physicians to com-
ply.
There is a long history of doctors succumbing to patient
pressure or expectations in the case of antibiotics. In a typical
year, doctors prescribe sorne 12 mil!ion antibiotic prescrip-
tions for treatment of colds, bronchitis, and other respira-
tory infections. Doctors may yield to requests for antibiot-
ics in such cases, even though these viral conditions almost
always fail to respond to this medication. This minor mal-
practice is worse than a waste of money: indiscriminate use
of antibiotics has contributed to the emergence of drug-re-
sistant strains, a growing problem in the U. S. and the rest
of the world.
Critics of direct-ro-patient advertising for prescription
drugs poin t to the 1997 [en-phen debacle as a wotst-case sce-
nario stemming from Madison Avenue tactics. Fen-phen (a
combined appetite depressant/amphetamine diet drug)
was approved by the FDA, and patients began calling their
doctors to demand (and get) the drug. The craze ended
suddenly when the manufacturer withdrew fen-phen from
the market at the request of the FDA, responding to reports
of grave heart abnormalities in many users of the drug.
Supporters of directly advertising rnedications to pa-
tients defend the practice as empowering clients with in-
formation. Opponents attack these paid messages as (al
misleading (e. g., failing to list al! side effects, exaggerating
benefits); (b) entangling laypersons in information they
may be unable to understand in context (since many of rhe
ads merely reprint the sarne information prepared for doc-
tors); (e) creating demand where often there is no real
need; (d) intruding into examining-roorn decisions; and
(e) wasting doctors' and patients' time. (Sorne companies,
to minimize practitioners' irritation, warn doctors before
direct-patient ads appear in their community.)
. 'o' t
Chapter 22: Facilitating Adherence to Treatment Regimens
RESEARCH ON ADHERENCE
Although nonadherence has plagued physicians through-
out the ages, formal research on this issue did not appear
until the 1940s. Adherence research has focused on (1) per-
centages of nonadherence in various patient populations;
(2) identifying characteristics of patient, provider, and set-
ting that predict nonadherence; and (3) testing interven-
tions designed to improve adherence rates. Adherence is an
interdisciplinary research area, and the nurnbers of repor ts
are burgeoning. The [ournal of Compliance in Health Ca re,
founded in 1986, is a periodical devoted to the study of
adherence.
Adherence and clinical outcomes. Dunbar-Iacob and
SchIenk (1996) reviewed studies which compared adhering
and nonadhering groups of patients in terms of clinical
outcome. These authors reported that there is a surprising-
ly srnall body of research on the role of adherence in treat-
rnent effects. (Note that it was only about 20 years ago that
the FDA began requiring the monitoring of adherence in
drug-efficacy trials.) The reviewers concluded that the
available data generally provided evidence of an adher-
ence-outcome relationship and suggested that efforts to
enhance adherence would lead to improved outcomes.
EXTENT OF THE POOR ADHERENCE
PROBLEM
Poor adherence is almost epidemic. For exarnple, reviews of
adherence research have shown that rate of patients' failure
to follow instructions for treatment ranges from 20% to
more than 80%, with the actual rate varying in terms of
patient population and operational definition used. One
example of such a review was done in 1991 by Dunbar-Ia-
cob and her colleagues, who included al! adherence re-
search studies that were published in the 1980s with hyper-
tensive patient populations. For medication taking, the
studies reported nonadherence rates ranging from 38% to
95%. According to these authors, the overall picture emerg-
ing [rom this body of research indicates nonadherence in ap-
proximately two thirds of the patients who were studied. This
figure for the past decade is disheartening, especially be-
cause it represents little or no improvement over the levels
of adherence found in 1970 to 1979 research studies.
Research has shown that patients with chronic condi-
tions (e. g., those with hypertension) are more vulnerable
to poor adherence than are those with short-terrn prob-
lems. Nevertheless, adherence is problematic even with
acute conditions. Patients are notorious for prematurely
discontinuing antibiotics, even if the regimen involves only
a limited number of days. This is also the case for parents
307
administering medication to their children who suffer
from conditions such as streptococcal throat or otitis.
Nonadherence has been found even in patients who have
undergone renal, liver, or heart transplants. This is the case
even though many such patients are still alive only because
a scarce organ was found in time, and even though trans-
plant centers screen candidates in terms of good adherence
to pretransplant regimen. AlI patients are counseled that
posttransplant nonadherence can result in loss of graft or
death. Nevertheless, researchers have found posttransplan-
tation nonadherence of up to 34% for adult renal patients
and up to 43% for pediatric renal patients. Research has also
shown that nonadherence is implicated in about 20% of
deaths or graft rejections in heart recipients.
IMPORTANCEOFADHERENCEIN
PREVENTIVE AND TREATlvJENT
REGIMENS
Preventive Regimens
In 1996, the Public Health Service (PHS) issued Healthy
People 2000: Midcourse Review and 1995 Revistons. This re-
port documents how well the nation is progressing toward
goals in 22 Healthy People 2000 priority areas. In 1990, the
PHS promulgated these goals as being high in priority and
attainable by the year 2000. (The goals represent a censen-
sus of ideas from health professionals and others in health-
related industries throughout the nation. More than 10,000
people provided input for selection of objectives.) The ma-
jor Healthy People 2000 goals are:
Increase the span of healthy life for Americans
Reduce health disparities among Americans
Achieve access to preventive services for all Americans
This midcourse review concluded: "Overall progress has
been made on the Nation's year 20g0 targets, with 50%
proceeding in the right direction, 18% moving away from
the targets, and 3% showing no change from the baseline.
Tracking data are not yet available for 29%."
The review stresses prevention as the foundation for
health: "As our knowledge about health and the potential
to prevent unnecessary disease and disability has increased,
the nationál perspective on health and disease has changed
dramatically. A 1994 assessment by the Centers for Disease
Control and Prevention estimated that nearly 47% of pre-
mature deaths among Americans could have been avoided by
changes in individual behavtors."
Seven of the 10 leading causes of death in America have
behavioral components. Effective interventions by health
care providers to improve patients' adherence in terms of
life-style improvements in such activities as alcohol and
308 Part 5: Making Decisions About Patients
illicit drug consumption, diet, exercise, smoking, unsafe
sexual practices, and seat-belt usage could bring us closer
to the goals of Healthy People 2000.
Adherence to life-style changes such as improved nutri-
tion, regular exercise, maintaining optimal weight, and ces- .
sation of smoking presents enormous challenges to both
provider and patient. Research indica tes that adheience to
lifelong preventive behaviors may be even more difficult than
adherence to treatment regimens.
Treatment Regimens. Findings on the widespread na-
ture of poor adherence to medication regimens have al-
ready been summarized in this chapter. Such nonadher-
ence can have dire consequences in terms of patient mor-
bidity and mortality, as well as adding to the cost of health
services.
The most common therapeutic intervention in medi-
cine is the writing of a prescription. Retail prescription
drug sales in the United States approached $150 billion in
2000 and will contínue to increase each year as our popu-
lation ages. Thus, poor medication adherence wastes liter-
a1ly billions at a time when growing costs are heightening
pressures to contain national health care expenditures.
In addition to endangering the patient, nonadherence
has the potential to lead to physical harm to others in the
community. For example, someone with epilepsy who fails
to take necessary medication and experiences a seizure
whíle driving may jeopardize the lives of not only himself
or herselfbut of fellow passengers or travelers in other cars.
An even greater threat to the community is posed by per-
sons with active tuberculosis (TB) who fail to complete their
medication regimen, which can last 6 or more months. Such
failure may a1low the bacteria to mutate into deadly, drug-
resistant strains. Nonadherent patients with TB are a threat
not only to themselves and their families, but also to health
care providers and other members of the cornmuniry.
There has been an alarming recent rise in deaths from
this airborne disease, such that Denver, for example, has
instituted "directly observed treatment," whereby patients
must be observed while they swallow their medication.
Even more drastic measures may be taken. In 1993, New
York City adopted strict regulations that could require con-
finement of patients with active TB who faíl to complete
treatment on their own; such detention could be required
for 1 or more years.
WHY 15 POOR ADHERENCE SO COMMON?
George C. Stone, a researcher at the University of Califor-
nia-San Francisco, has asked a question that expresses the
puzzlement (and perhaps exasperation) experienced by
many providers and researchers:
Why would someone who has gone to the trouble and
expense of seeking out a physician, of undertaking ardu-
ous or uncomfortable tests and other diagnostic proce-
dures, and of purchasing drugs and devices on the ad-
vice of the physician, then fail to follow the recommen-
dations?
Researchers on adherence seek answers to this riddle in
hopes of providing at least partial solutions to the noriad-
herence problem.
The major explanatory models used in adherence re-
search focus on patient beliefs and expectancies. The im-
portant conceptualizations inelude the health belief model
(HBM), self-efficacy theory, and the theory of reasoned
action. Despite the existence of these various models, there
is theoretical convergence on the importance of five factors.
That is, research shows that patients are most likely to ad-
here when (1) they perceive the severity of the disorder is
high (serious consequences), (2) they believe the probability
of their getting the disorder is also high (personal suscepti-
bility), (3) they have confidence in their ability to perform
behavior or behaviors prescribed to reduce the threat (self-
efficacy), (4) they are also confiden t the prescribed regimen
will overcome the threat (response-efficacy), (5) and they
have the intention to perform the behavior or behaviors
(behavioral intention). Thus, these elements can be sum-
marized as the "double high/double efficacy/behavioral
intention" model.
Utility of the Health Belief Model and 5elf-Efficacy
Framework
The Health Belief Model (HBM) is perhaps the most in-
fluential and intensively researched theory of what moti-
vates patients to adhere or not adhere to a wide spectrum .'1
of regimens, ineluding breast self-examination, control of
hypertension, managing diabetes, use of well-infant clinics,
and prevention of coronary heart disease. Research over 20
years has documented that the HBM can predict whether
patients adopt certain health behaviors, For example, it has
be en a common finding that patients who are poor in ad-
herence tend to see themselves as less threatened by and
less susceptible to illness that is diagnosed by a provider.
Albert Bandura's (1986) research has identified pattent's
perceived self-efficacy as an importan; mediator of adherence-
Bandura defines perceived self-efficacy as "a judgment of
one's capability to accomplish a certain level of perfor-
mance." The patient's self-judgment, whether it is veridical
or faulty, is said to be based on four major informational
sources: (1) performance attainment (the most influential
source of self-efficacy information), which is based on the
patient's own authentic mastery experiences; (2) vicarious
experience, which involves having the patient see or visual-
ize similar others perform successfully; (3) verbal persua-
sion, which stems from having the provider or other people
try to persuade the patient to adjust his or her self-efficacy
 Chapter 22: Facilitating Adherence to Treatrnenr Regimens 309
judgments; and (4) physiological states, which concern in-
ternal cues such as somatic arousal in taxing or stressful
situations that the patient uses as evidence of physical ca-
pability or deficit.
Bandura's conceptualization has, for example, provided
insights that were use fuI in treating patien ts recovering
from myocardial infarction (MI). Because many MI pa-
tients remain fearful of exertion long after they have recov-
ered, the professional faces the chal!enge of restoring the
patients' confidence in their cardiac efficacy.
Bandura recommends using evidence from al! four
sources of information in programs designed to restore the
patient's sense of physical self-efficacy. Performance effica-
cy information can be cogently conveyed by treadrnill ex-
ercises; vicarious efficacy information can be obtained
from visits with former patients who now successfully lead
active lives; persuasive efficacy information results from in-
forming the patient about his or her physical capabilities;
and finally, the patient can be taught how to interpret phys-
ical efficacy information correctly so as not to misread nor-
mal signs of exertion as signs of another heart attack. Ban-
dura cites evidence that the patient's perceived physical cCl-
pabi/ity predicts tesumption of an active life better than does
cardiovascular capacity as measured by the treadmill.
Research has shown the self-efficacy framework to be
helpful in such health-related activities as improving respi-
ratory volumes and capacities in patients with lung disease,
Age and eyesight may be two factors affecting adherence Courtesy of
controlling tension headaches, and breaking the smoking
the National Insritute on Aging.
habit. Bandura advises the provider to conduct self-efficacy
probes throughout the course of treatment to facilita te ad-
herence. there is evidence that such adherence would yield enor-
mous rewards, such as slowing or even preventing the onset
of blindness, kidney failure, heart attack, or amputation in
diabetic patients. The latest research on diabetes manage-
FACTORS ASSOCIATED WITH ment yields strong evidence that a strict innovative regi-
ADHERENCE men (including use of home monitoring ofblood sugar up
to 10 times daily and multiple insulin shots each day) could
Literally hundreds of variables have been studied as poten- greatly reduce (or eliminate) dire complications of diabe-
tially relevant to adherence. An overview of sorne major tes. After publication of these findings in the media, diabe-
variables follows. tes centers across the nation geared up for an avalanche of
patients seeking the new treatrnent. However, experts were
disappointed at the low level of requests for the innovation;
Characteristics of Disorder and Regimen these experts speculated that the innovative daily regimen
as a lifelong practice is daunting to many persons with di-
Research has genera/ly [ound that: (a) Adherence is /ikely to abetes. One exception lies with diabetic women contem-
deteriora te over time, (b) adherence is more problematic for plating pregnancy; these women are generally highly rno-
asymptomatic conditions, especially if treatment entails aver- tivated to maintain even an extremely tight control during
sive side effects, and (c) complexity (e. g., number of and the 9 moriths of pregnancy if it improves their chances for
scheduling of medications, special tnstructlons) of the regi- ahealthy infant.
men is negatively related to good adherence.
Consider, for example, the triple whammy delivered to
a hypertensive patient put on a lifelong medication regí- Physician and Setting
men, yet who experiences no overt symptoms except for
reduced or absent sexuality as a side effect of medicine. It is no surprise that a physician's ability to empathize and
Cornplexity of regimen can lower adherence even when communicate with patients is essential for good patient co-
 310 Part 5: Making Decisions About Patients

operation. For example, research shows that physicians'

sensitivijv to such nonverbal expression of patients' feel-
irígs as tone of voice predicts adherence.
A large-scale study by DiMatteo and her colleagues
(1993) longitudinally followed more than 1,800 patients .
suffering chronic diseases (diabetes, heart disease, or hy-
pertension) and their 186 physicians. The research showed
. that physicians' own job satisfaction, their willingness to all-
swer questions, and the practice of scheduling a [ollow-up
appointment were powerful predictors of adherence.
Other research has shown that longer waiting time is
related to poorer adherence and that clinic staffs that pro-
vide warrn, personalized approaches are likely to obtain
better adherence.

Patient Characteristics

The 1993 study by DiMatteo and her colleagues followed

participants for 2 years. Baseline adherence rates predicted
adherence 2 years later. Thus, patients who tended to start
off right tended to end up right.
As discussed earlier, patients' cognitions and attitudes are
important conelates of adherence: perceptioris of personal
vulnerability, severity of disorder, self-efficacy, response ef-
ficacy, and intentions are all good predictors of adherence.
Patient coping style is also relevant. For example, recent
research with a large sample of patients with chronic con-
ditions found that patients using strategies to tune out the
problem (such as making themselves feel better by eating,
smoking, or drinking; or sleeping more than usual) were
less likely to adhere. As one might expect, patients satisfied The Bath Mary Cassatt (1891-1892). Oil on canvas, 100 x 66 cm.
with the interpersonal quality and financial aspects of their Robert A. Waller Fund. Even well-intentioned paren 15 often fail lo [oliow
treatment recommendations for their children.
ca re were more likely to adhere.

tion. However, living conditions make adherence extrernely

Social Support
Family, friends, coworkers, or support groups can play an
important role in encouraging the patient (through infor-
mation, tangible aid or emotional help) to achieve health
goals.
Homelessness
Homeless persons in America probably represen: medicine's
greatest challenge. It is difficult to fathom the extent of ad-
versity which confronts most homeless persons, many of
whom suffer multiple problems such as physical disorders,
mental illness, and drug addiction, Even homeless persons
in good health can find the task of finding food, access to
toilet facilities, a way to keep clean, and a place to sleep to
be an all-consuming daily struggle.
Little research has focused on adherence in this popula-
difficult even for the highly motivated homeJess persono
Shelters for the homeless are likely to Jack even such hum-
ble amenities as calendars or clocks, so keeping rrack of
medications or arriving on time for a physician appoint-
ment may be extremely challengíng if not impossible. Med-
ications are likely to be stolen, and poor nutritional content
of much of the available food makes clietary adherence for
diabetes or hypertension problematic. Even trying to keep
a clean bandage on a wound represents a formidable un-
dertaking for a homeless persono
Ethnicity
The U. S. population continues to grow and diversify. The
Census Bureau projects a combined mino rity population
of 33% by the year 2015. AlI available statistics show that
there are robust ethnic differences in American health out-
 Chapter 22: Facilitating Adherence to Treatment Regimens
comes. Health researchers are aware of these differences,
but are uncertain as to why they exist.
Sorne experts cite structural factors (such as differential
access to health care) to explain these ethnic differences.
Other possible explanations cited inelude cultural, biologi-
cal, genetic, social class, or religious differences. In any event,
Pamela Kato at the Stanford University School of Medicine
has reviewed the data on the ethnic-health relationship and
coneluded that "general health interventions can be more
effective if they are targeted toward ethnic groups."
Practitioners may want to consuIt Smith and Lin's 1996
review on how biological, environmental, and cultural fac-
tors can produce ethnic differences in responses to rnedi-
cations. The latest research has found significant variations
in how ethnic groups respond to several elasses of medica-
tions, ineluding psychotropies, analgesics, and cardiovas-
cular agents. In summary, ethnic variation in drug response
is an issue of growing importance as the U. S. population
becomes increasingly heterogeneous.
Use of Alternative Medicine
Sorne persons may seek treatment in the standard system
ofhealth care, while simultaneously using alternative med-
ical treatments. Provided the alternative interventions are
not deemed to be harmful or to interfere with the modern
scientific regimen, American providers can presumably
learn to live in peaceful co-existence with these alternative
practices. (A physician who seeks to dissuade a patient
from practices deemed maladaptive must, of course, do so
with tact, even compassion remembering that these prac-
tices may be part of the patient's cherished beliefs or cul-
311
Expectations help determine outcome
in any clínica] setting. Courtesy of the
National Kidney Foundation, Inc. Learn:
ing how lo shape patient expectations will
help you become "a healing sort 01person."
tural heritage.) Detailed information on alternative medi-
cine is provided in Chapter 5.
INTERVENTIONS TO IMPROVE
ADHERENCE
While a doctor's recommendation is an important predictor
of successful behavior change, the adherence literature co-
gently demonstrates that physicians or other providers can-
not merely assume their job is done after diagnosis and pre-
scription of correet treatment. Good practitioners do not
automaticaUy conelude that the rest is up to the patient. If a
patient is nonadherent, it may be that.he or she does not (1)
know what to do (knowledge deficit), (2) know how to do
it (skills deficit), or (3) want to do it (motivation deficit).
The physician plays an important rolein all three areas.
Knowledge and Information
The physician's job ineludes adequately informing the pa-
tient, but many physicians are overworked and pressed for
time. Research shows that many patients, however eager to
get more information, are reluctant to take Llp a physician's
time with questicns. Moreover, physicians often overesti-
mate the time they spend providing information for pa-
tients. (One study showed that a sample of physicians esti-
mated they spent between 10 to 15 minutes informing eaeh
patient, but the actual average was 1 minute!) Obviously,
soliciting patient's questions and taking sufficient time to
answer these questions are part of good practice.
312 Part 5: Making Decisions About Patients
In addition, presenting information in a clear, persuasive
manner is important. Decades of research have yielded
principles that can be translated into practical advice on
how to get people to adhere. The list in Box 22.1 may be
helpful in this connection.
BOX 22.1 Communicating information
Start Strong. People remember fírst and last points best; save
your best ammunition for the beginning and end.
Use a short, clear, direct style. Otherwise the patient will tune
you out.
Use the active voiee. "This medication will control your sei-
zures" is better than "Your seizures will be controlled by ... "
Accentuate the positive. "This drug has a 75% success rate" is
better than "This technique has a 25% failure rate."
Substitute a vivid message for jargon. A videotape of a former
patient who has recovered from a disease now diagnosed in a
current patient is worth a thousand words.
The source of the message should be prestigious and trustwor-
thy.Physicians and nurses generally have high credibility. Citing
the surgeon general wiil be more credible than citing someone
with less status. .
Tailor your strategy to what you know about the patient. People
who favor a health message need to hear only supportive argu-
ments; the provider need not rebut arguments that the patient
does not accept anyway.Bu! if a woman thinks she is too busy to
exercise,for example, the provider may want to indicate ways
exercise can be incorporated into her daily routine by use of the
stairs instead of the elevator. .
Explicitly make your point. For exarnple, advise the patient to
use the stairs and to walk every time he or she can. . and response-efficacy).
End strong. Written instructions, preferably custom made to the
patient's condition, are also advisable, especiallywhen patients
need reminding of instructions they may have forgotten.
Upsetting Inforrnation
A diagnosis of disease can be viewed as an opportunity for
providers to act as change agents. On the other hand, when
a negative diagnosis is first disclosed, the news may make
the patient so anxio us that he or she is unable to attend to
the rest of the provider's message. In such cases, the pro-
vider should schedule a foUow-up appointment when the
patient is better able to listen, understand, and ask ques-
tions.
Reducing Complexity o] Regimen
Complexity of regimen is negatively related to adherence, so
providers should make the regimen as unobtrusive and
simple as possible. Advice from a pharmacist can help in
ways to simplify medication regimens.
Skills Training
Patients may lack the necessary skills required to adhere to
their regimen. For example, they may need to learn how to
inject a daily insulin dosage, how to select low- fat foods, or
how to become more assertive in resisting social pressure
to overeat, use drugs, smoke, or engage in unsafe sexo
Sorne disadvantaged patients may need guidance and
assistance in applying for financial entitlements to pay for
treatment. In such cases, the provider should arrange for
heIp from a social worker or social service agency.
In many localities workshops addressing specific areas
that require training are periodicaUy available. For exam-
pie, a workshop may focus on teaching sexualIy active ad-
olescents how to negotiate safe sex practices, including
what to sayand do when a partner balks at use of a condom.
The provider will want to get on mailing lists to receive
announcements of such workshops to share appropriate
information with their patients.
Motivation
NaturalIy physicians must play an irnportant role in moti-
vating good adherence. Communicating diagnoses and
prescribing regimens can inelude important elements that
are related to adherence (e. g., helping the pa tien t to realize
severity of conditicn, personal vulnerability, self-efficacy,
A physician's request can be a powerful motivator, as dem-
onstrated by an experirnent involving mothers of children
with otitis media. Half these rnothers were asked by their
physician: "Will you promise me that you'll give al! the
doses?"; all mothers said yes to this request. These mothers
adhered significantly better than did those who were not
asked to make a prornise.
Fear
The role of fear in motivating health behaviors is controver-
sial. First, sorne providers shun fear tactics as coercive and,
consequently, unethicaI. Secorid, decades of research on rhe
effectiveness of fear in motivation shows conflicting results
on whether high levels of fear may be counterproductive.
Although unresolved theoretical issues remain, there is
consensus that fear can playa part in persuading people. for
exarnple, to exercise more and eat less. However, the provid-
er is advised to induce a relatively low level of fear, because
high threat may invoke inappropriate behaviors such as tun-
,
<
ing out the message or denial. Instead of focusing on long-
range consequences, stress the more irnmediate physical
j
t
drawbacks (e. g., lack of energy or puffing when climbing -
.
stairs) of overeating and underexercising.
,
,:~.
,
 Chapter 22: Facilitating Adherence to Treatment Regimens
QTHER vVAYS TO IlvlPROVE
ADHERENCE
Behavior Programs
Behavior management programs are particularly use fuI in
efforts aimed at Iifelong improvements in health-related
behaviors, such as attaining and maintaining weight reduc-
tion. These programs use techniques derived from research
on learning and habit formation. Discussion of sorne im-
portant elements typically included in such programs fol-
lows.
Self-monitoring. Understanding the dimensions of a be-
havior targeted for change can facilitate the process of
change. Wirh self-monitoring, the patient engages in sys-
tematic self-observation, which ineludes learning to antic-
ipate and recognize the target behavior, chart its occurrenc-
es, and document the surrounding circumstances. Thus, an
obese person can learn to identify the timing and pattern-
ing of urges to eat, including internal sensations, social
stimuli (e. g., stress resulting from arguing with a spouse),
and the circumstances in which eating is likely to occur.
Self-monitoring is a useful first step in starting any
change, because a more complete self-understanding better
prepares the patient to recognize exactly what behaviors
need to be modified.
Stimulus control. Stimulus control involves such prac-
tices as altering the patient's environrnent to make behavior
change as convenient and comfortable as possible and add-
ing reminders to promote behavioral change.
For exarnple, a person is more likely to use an exercise
machine when it is set up in the family room near the tele-
vision set than when it is sto red in a doset. Also, it is easier
to abstain from fattening foods if such foods are removed
and never again brought into the home.
Reminders are also helpful. The Stanford Heart Disease
Prevention Program developed tip sheets to summarize
risk reduction strategies, briefly and elearly, on color fui
pie ces of paper. Tip sheets on the refrigerator might en-
courage consumption of low-fat foods.
Contingency contracto A contingency contract is a writ-
ten agreement in which the patient agrees to specific be-
havior changes and outeomes by stipulated deadlines; re-
wards or penalties for eompletion or noneompletion of the
agreement are also speeified. The rewards and penalties in
the contraet pro vide ineentives for the patient to aeeom-
plish speeifie goals by given dates.
An example of a eontingeney contraet is given in Box
22.2. The eontraet should be customized to meet the spe-
cific, unique needs of the patient and in elude a time frarne,
spell out specifie goals, as well as sehedules of rewards or
penalties, specify methods of reeord keeping, and make
provisión for renegotiation.
313
BOX 22.2 Example of a contingency contract
Behavior Change Contract for Ms. [ane Doe
- Dates to be reviewed: Monthly for the next 12 months. 1, Iane
Doe, agree to lose 1 lb each week. 1 will achieve this goal by:
exercising at least 30 minutes on 6 out of 7 days each week
and willlimit my consurnption each day to 1,200 calories,
with daily fat grams not to exceed 60. Of the 1,200 calones,
only 150 calories may be consumed in the form of sweets or
other junk food. 1 will also attend Weight Watchers for at
least 3 meetings during every 4-week periodo
- Record keeping. Each day 1 will accurately monitor each of the
following: minutes of exercise; total calories consumed;
number of fat grams; number of calories from sweets or junk
food. I will also monitor attendance at Weight Watchers. 1
will accurately record this information on the chart provid-
~d.
- Meeting gaals. Each week that I meet my weight goal, my
spouse will take me for a special noncaloric treat, such as a
rnovie.
If at the end 00 months, 1have lost atleast l2lb, the cosign-
er of this contract will furnish me with $50 from lile $100
deposit that 1 make in signing this agreement, with the mon-
ey to be spent on a facial and hair-style. If at the end of 6
months, I have kept off at least 12 lb, the balance of my de-
posit will be made to me for another visit to the hair dresser.·
- Failing to meet goals. If 1faíl to lose the stipulated weight for
any 2 weeks, 1 will not Jet rnyself watch my favorite sitcorn,
"The Ierry Seirifeld Show," for the next 2 weeks, At the end of
6 months, in fail to keepoff at least 12 lb, the bala~~e of any
remaining deposit wiIl be donated to the National Rifle As-
sociation, an organization whose goals I despise.
. [ane Doe
Provider's name
Date
Utility of Behavior Management Techniques
The reader may wish to consult M otivating H ealth Behavior
for a more detailed diseussion of how behavioral teeh-
niques can further health eare goals. Brownell and Kramer
(1989) give a detailed explanation of how to apply the tech-
niques to the treatment of obesity.
Relaxation Training
Relaxation training is a prornising, widely used nonphar-
maeologieal intervention found to be useful with ehronic
illnesses. For exarnple, it has helped in the alleviation of
anxiety and nausea from chemotherapy, thus making it
easier for patients to eontinue with their regimen.
314 Pan 5: Makíng Decisions About Patients
Support Groups
¡
Personally experiencing an illness often provides a patierit
with the unique perspective of an "insider" who possesses
special knowledge and insight that cannot be obtained in .
any other way. These insiders often form self-help groups
to accommodate persons who share a common problem.
Sorne 7 mil/ion persons attend various self-help groups,
amollg which Alcoholics Anonymous is probably the oldest
and most successjut. Self-help groups can assist in a wide
variety of circumstances, including coping with cancer,
rearing children with Down syndrome, and dealing with
meno pause.
Persons sharing the same challenge regularly meet to
assist each other; a counselor may or may not be present.
The empathy, understanding, and social support in these
groups can help mernbers adhere to their regimens. A re-
cent review concluded that these groups are well on their
way to becoming a legitimate source of aid that will chal-
lenge professional counselors as providers of help.
Modeling
Patients can learn by observing another person enact a be-
havior. A patient recovering from a mastectomy can learn
appropriate exercises from someone fully recovered from
the operation. (This is an example of self-efficacy derived
from vicarious experience.) Self-help programs such as Al-
coholics Anonymous and weight-Ioss support groups in-
corporate the principIes of modeling.
RELAPSE PREVENTION
Because recidivisrn is both dangerous and common, re-
lapse prevention (RP) is becoming an increasingly irnpor-
tant aspect of health careo Re/apse is especia/ly problematic
with SllCJ¡ addictive disorders as overeating and smoking, [ot
which re/apse rates range [ro m 50% to 90%.
A lapse is likely to happen to anyone. However, the re-
sults of even one failure may lead to negative feelings and
statements about the self, a decreased sense of self-efficacy,
and perhaps even abandonment of further attempts to ad-
here.
Relapse has been linked with such factors as aversive
emotional sta tes (e. g., depression, stress), lack of social
support, waning of motivation, and being exposed to
temptation (e. g., a friend asks a recovering alcoholic in for
a drink). Also, lifelong behavior change often involves wait-
ing a long time for rewards. For an obese person, long-
range reward (e. g., a healthier, more attractive body) can
be less powerful than the immediate reward of delicious
food.
Marlatt and Gordon (1985) have proposed an RP ap-
proach that emphasizes teaching skills and changing atti-
tudes to enable the patient to cope with the inevitable lapse.
An additional strategy teaches patients how to identify their
own "high risk for lapse" situations to make appropriate
life-style changes to elimina te or reduce such risks. For ex-
ample, a young man with such training is able to recognize
that he is more likely to engage in unsafe sex after drinkíng.
He is now in a position to limit (or eliminate) alcohol in-
take whenever a sex partner is Iikely to be available.
Marlatt and Gordon stress that RP skills must be taught
as par t of the treatment regimen right from the beginning.
If initial commitment to the change is low, RP training
must start with strategies to increase motivation so that the
patient is truly committed. (Whether persons who fail to
achieve initial commitment should be screened from be-
havior change programs is controversial.)
BOX 22.3 Guidelines to adherence-friendly practice
- Be a patient-friendly resource: Take sufficient time, show a
caring attitude, be understanding.
- Make the treatment as user friendly (e. g., simple, brief) as
possible.
- An ounce of preventíng.nonadherence is worth a pound of
trying to cure it. Ensure that the patient is ready, willing, and
able to adhere from the beginning.
- Do not overload the patient with information; it may be bet-
ter to share information across two visits, Do not try to in-
form unless the patient is calm and can attend to the mes-
sage. Have patients surnmarize their understanding of their
condition and treatment at the end of the visit
- Do not be naive. Alrnost all patients slip at least occasionally,
and so will yours. Even a simple question such as "Are you
having any trouble taking your medications as prescribed!"
can uncover adherence problems. Express sympathy ("It
must be hard to keep track of your medications") rather than
anger at any disclosure of nonadherence.
- Increase patient involvernent in treatrnent, For exarnple,
make sure the patient understands why a folJow-up visit is
needed: you may want to negotiate with the patient about
the appropriate interval between foUow-ups. At the very
least, have patients monitor and record their adherence be-
haviors, and go oyer this material with the patient.
- Use foUow-up appointments, telephone/postcard reminders,
calendars, and other written material to improve adherence.
- Be a gold mine of information for the patient. A Rolodex of
community resources for patient referral (e. g., social service
agencies) is a must.
- Be sure the patient has the support of significant others; join-
ing a relevant support group may help the patient.
- Contract with patients to achieve goals by reasonable dead-
lines, especiaUy when treatrnents are lengthy.
- Be creatíve in applying one or more of the interventions dis-
cussed in this chapter, as needed by the patient.
- Realize that facilitating adherence and preventing nonadher-r-
ence are part of your job description. .
 Chapter 22: Facilitating Adherence ro Treatrnent Regimens
More recent research has shown that a multifaceted
maintenance program, including posttreatment contact
with the therapist designed to solve the patient's specific
problerns, has improved long-term results for the mainte-
nance of weight loss.
SUMMARY
Nonadherence, which is often unrecognized by the physi-
cian, is both common and potentially dangerous. Physi-
cians must play an active role in facilitating adherence in
their patients. Such facilitation first requires that the phy-
sician be aware of the adherence problems in his or her
patients. See Box 22.3 for a list of sorne practices that
should be routinely used by physicians to ensure high ad-
herence efficacy in their patients. Good practice requires
that responsibility foroadherence must be shared between
provider and patient.
CASESTUDY
Anne Fadiman (1997) has written about a real-life tragedy
stemming from the c1ash of two cultures: Western medicine
vs. the animist culture of the Lee farnily, Hmong refugees
who fled from the mountains of Laos and settled in central
California.
Lía, baby daughter of the Lees, is severely epileptic. The
desperately sick baby was taken to the hospital, but the Lees
balked at the complicated regimen of drugs prescribed to
stop the devastating attacks. The Lees believed that the sei-
zures were causedby fugitive spirits (called dabs) who had
caught Lia's soul and made her fal! down. They preferred
to treat her by means of animal sacrifices, which they be-
lieved would persuade the spirits to give Lia her soul back.
Then the seizures worsened, and Lia suffered irreversible
brain damage. The California doctors blamed the parents
for failing to adhere to the medical regimen. The Lees
blamed the doctors, attributing Lia's worsened condition
to overmedication.
The common ground shared by the two sides was a corn-
mitment to do their utmost to make Lía a healthier baby.
The baby was admitted to the hospital 17 times (despite the
Lees' total inability to pay), so the parents must, at least
initially, have had sorne shred of faith in Western medicine.
But their Hmong worldview prevented them from recog-
nizing the good faith and expertise of the doctors, nurses,
social workers, and foster parents who became involved in
Lia's careo
The Western professionals blamed the parents' supersti-
tious worldview and self-defeating ignoran ce for Lia's
heartbreaking outcome. On the other hand, Fadiman, the
315
book's autho r, concluded that Lia's life was ruined not so
much by nonadherence as by a cultural misunderstanding.
Fadiman views the animist beliefs of the Hmongs not so
much as ignorance as another kind of knowledge.
It is noted that adherence is usually lower when a com-
plicated, long-term regimen is involved, as is the case here.
Compounding the difficulty of achieving adherence is the
parents' disbelief in the rnedicine's effectiveness and their
perceived lack of self-efficacy in adhering to the medical
regrmen.
SUGGESTED READINGS
Bandura, A. (1986). Socia/ [oundations for though: and action. Engle-
wood, NJ: Prentice-Hall.
Chapter 9 on self-efficacy presents information useful to the prac-
titioner,
Brownell, K., & Krarner, F.(1989).Behavioral management of obesiry,
Medical Clinics ofNorth America, 73,185-201.
An excellent review of how behavior management can help obese
people; it details elernents of the treatment as well as of interven-
tíons to prevent relapse.
DiMatteo, M.R.. et al. (1993). Physicians' characteristics infIuence pa-
tients' adherence to medical treatment: Results from the medical
-outcomes study. Healtn Psychology, 12,93-102.
The article idcntifies physician variables that correlate with pa-
tient adherence,
Dunbar-Iacob, J.. Dwyer, K., & Dunning, E. (1991). Compliance with
antihypertensive regimen: A review of the research in the 1980s.
Annals of Behovioral Medicine, 13, 31-39.
This review of 1980-89 studies details the patient variables related
to adherence in patients with hypertension and the extent of non-
adherence.
Dunbar-Iaccb, J.. & Schlenk, E. (1996). Treatrnent adherence and
clinical outcome: Can we make a difference? In R. Resnick and R.
. Rozensky (Eds.), Health psychology through the life span (pp. 323-
343). Washington, OC: American Psychological Association.
This reviews the research on the adherence-health relationship.
Elder, J., Geller, E., Hovell, M., & Mayer, J. (1994). Motivating' healtl:
behavior.1\TY: Delrnar Publishers.
Chapters 8,9, and 12 are most relevant t:o~practitioners interested
in behavior management techniques deii'gned to train, motiva te,
and change health-related behaviors. :J:.
Fadirnan, A. (1997). The spirit catches you and yOIl faU dO\VlI: AH mong
child, her American doctors and the collision of t\Vo ClIlt 11res. New
York, NY: Farrar, Strauss, & Giroux.
The title sumrnarizes the elernents in a tragic misunderstanding
that ruined a child's life.
Kato, P. (1996). On nothing and everything: The relationship between
ethnicity and health. In P. Kato & T. Mann (Eds.), Handbook of
di~mity iS511e5in health psychology (pp. 287-300). New York, NY:
Plenum Press.
.An overview of what is known about the irnportance of ethniciry
in health careo
Marlatt, G., & Gordon, J. (1985). Relapse preventton. New York; NY:
The Guilford Press.
This text presents an overview of Marlatt's relapse prevention
316 Part 5: Making Decisions About Patients

. model; it contains chapters on application of the model with ad-

dictive lifestyles (alcoholism, smoking, overeating).
I
Smith, M., & Lin, K. (1996). A biological, environmental and cultural
basis for ethnic differences in treatment. In P. Kato & T. Mann
(Eds.), Handbook of diversity issues in health psychology (pp. 389-
406). New York, NY: Plenum Press.
This chapter reviews the available evidence on ethnic differences
in reactions to drugs.
Taylor, S., & Aspi.nwall, L. (1990). Psychosocial aspects of chronic
illness. In P.Costa, Ir. & G. VandenBos (Eds.), Psychological aspects
o[ serious illness. Washington, DC: American Psychological Asso-
ciation.
This is a briefbut comprehensive review of psvchosocial variables
(e. g., health attitudes and behaviors) as well as cognitive and
behavioral interventions, as related to chronically iUpeople.
U. S. Department of Health and Human Services, Public Health Ser-
vice. (1996). Healthy people 2000 midcourse ret'iew and 1995 revi-
sions. Sudbury, MA: Iones & Bartlett Publishers,
This review summarizes what has been achieved during the first
5 years of the decade-Iong campaign involving health care goals
to be attained by the end of the century.