Adherence in Patient Education: Introduction

Health care professionals consider a patient compliant when he or she follows their recommendations for health care management. In contrast, a person is „non-compliant“ when he or she ignores treatment recommendations or doesn’t follow them correctly. In nursing, noncompliance is defined as „unwillingness to practice prescribed health-related behaviors.“1 The term „adherence“ has recently replaced the term „non-compliance,“ as the latter term was thought to be inappropriate in some patient situations.2 The extent to which patients follow health care instructions is a major issue in health care today. Nurses and other health care professionals are frequently frustrated when patients don’t follow instructions despite their best efforts to help patients maintain optimum health. Although we sometimes conclude that a patient is unmotivated, it is important to remember that the transfer of health care information from one person to another and the decision to act on advice is a complex process.

In making personal decisions about adherence to treatment recommendations, patients may react in any of the following ways:

  • They may totally accept and adopt the recommendations given without question.
  • They may totally ignore the information given and continue in the current pattern of action or inaction despite personal consequences to health and well-being. An example of this is the patient who continues to smoke three packs of cigarettes a day despite evidence that smoking has serious health consequences.
  • They may appear to have decided to follow the instructions, but actually choose to follow only selected aspects of the recommendations, delaying some suggestions, or blaming events for their inability to follow all the recommendations.
  • They may disregard instructions that seem threatening or impossible to achieve, and search for easier solutions to problems.
  • They may weigh the pros and cons of instructions given, seek additional information, and make a decision of whether or not to follow the instructions based on their investigation and assimilation of the information obtained.

In some situations, the way in which we provide health care education doesn’t help patients adhere. For example, some health care professionals conduct patient education by simply giving patients information about their problems and treatments. Others believe that the quality of patient education is based on the availability of audiovisual programs, well-equipped file drawers, and visible informative posters. In addition, if patients fail to perform the desired behaviors, we often assume that they were not given enough information or that they failed to assimilate it. Instead of questioning our assumptions, we respond by repeating the information or giving it in a different form.

In other situations, the patient has difficulty making the changes recommended. It is important to keep in mind that the health behaviors we often suggest for patients involve not just one change, but changes involving many difficult daily decisions. Many of the lifestyle changes we expect patients to make may involve pain, expense, social isolation, a perceived loss of independence, and the difficulty of breaking old habits. We all know from personal experience that changing a single behavior pattern, such as starting an exercise program or going on a low fat diet, is difficult. Yet, we frequently ask patients to change two or more behaviors-such as going on a diet, starting an exercise program, and stopping smoking all at the same time.

Concern about patient adherence with health care teaching has a long history-even Hypocrites is reported to have complained about patients being non-adherent with treatment instructions.

In the past, patient education often consisted of giving patients information that the health care professional thought necessary rather than information based on the patient’s need or desire to be better informed. Little attention was given to whether patients actually understood the information and whether they actually made changes needed. It was assumed that patients would follow instructions because the health care professional was in a position of authority. When it became clear that patients did not follow specific instructions, rather than evaluating what might have been wrong with the process or what factors may have prevented the patient from following treatment advice, health professionals sometimes labeled the patient as uncooperative or noncompliant.

Research findings consistently demonstrate that physicians significantly overestimate what patients understand when discharged from the hospital. Physicians in one study thought that 89 percent of their just-discharged patients understood the side effects of the medications they were taking and that 95 percent knew when to resume normal activities. However, only 57 percent of the patients said they actually knew the side effects of their medications, and 58 percent knew when they could resume normal activities. Although some health care professionals in the past may have concluded that patients didn’t want to know about their diagnosis and treatment, surveys contradict this conclusion. Research has shown that 99 percent of patients want to know what the treatment will accomplish, 98 percent want to know the side effects of their treatments, and 95 percent want to know exactly what the treatment will do inside their bodies. The same surveys indicate that the majority of patients feel that deciding what is done about their medical condition should be a shared decision between the physician and the patient. Despite this evidence, many more patients feel they have too little control over their treatment than feel they have too much control.

Impact on treatment recommendations