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.