Introduction

The topic of my discourse is my hopefully successful attempt at answering the following

question: Why do patients not adhere to treatments? I am going to develop and build around this
subject by discussing it in relation to sociological explanations, as well as applying the concepts I
will talk about to a particular disease (as you will discover in the following minutes). The main
idea of this discourse is non-adherence to treatments; therefore, I will base my arguments on
general definitions of specific key-terms I will consistently use throughout my presentation (such
as health) and I will go through the specifics of some concepts such as the medical body, lay
perspectives, doctor-patient relationships. What is more, my presentation will be rounded by
theories emitted by authors such as Talcott Parsons, Elliot Freidson, Robert Horne and others. To
give proof for the hypotheses introduced in my presentation, I will further elaborate the reality of
non-adherence to treatment in the case of type 2 diabetes.

Analysis
To begin with, defining health is not an easy process: it requires more than just a
standardized formula due to the fact that, in itself, health is complex and changes according to
situation and context. Discipline-specific parameters should be given in order to establish
whether someone is in “good” health or not. According to the World Health Organization
[CITATION Pre48 \p 100 \l 1033 ] , “health is a state of complete physical, mental and social well-
being and not merely the absence of disease or infirmity”. To be completely fair, this definition
is rather old, utopian and undermines the human capacity of coping with difficulties such as
chronic diseases; these criticisms have been observed in an article by [ CITATION Hub11 \l 1033 ]
and they are simultaneous pieces of evidence that there are two broad perspectives that can be
used to define health. Health professionals have either a negative or a more positive approach,
depending on which side we’re analyzing (either emphasizing the absence of certain qualities or
highlighting the presence of other qualities), while lay people tend to define health positively,
negatively or functionally (i.e. fitness and well-being, absence of illness, respectively the ability
to cope with every-day activities).

Keeping in mind that health is complex and that it changes in order to fit specific
parameters, it is also necessary to observe the medical model and its main foundations which are
the mind-body dualism (The Estranged Body), the mechanical metaphor (The Fragmented
Body), the technological imperative (The Transparent Body), the reductionist (The Standardized
Body) and the doctrine of specific aetiology (The Molecular Body) [ CITATION Net13 \l 1033 ].
Each foundation is reserved for a specific medical body and each medical body has a self-
explanatory nomenclature. It is important to note that diseases are the main focus of the medical
model and are being perceived more and more from a reductionist perspective, meaning that the
actual experience of disease is considered, observed and treated as if it occurred in a social
vacuum. In doing so, the Human Genome Project [ CITATION NIH21 \l 1033 ] was born and,
throughout more than a decade, researchers tried to map and understand all the genes of human
beings. None of this would’ve been possible without having a grasp of the medical model and its
foundations.

Taking this into consideration, I have to carry on with the lay perspectives. In antithesis
to the health professionals’ opinions, lay perspectives are “non-medical, non-expert” and they
refer to how people respond to, interpret and actually experience health, illness and disease.
These points of view are relevant to the sociology of health and illness because, as stated by
[ CITATION Mac02 \l 1033 ], “health professionals need to comprehend the ways in which people
critically assess, modify, reject and accept formal messages about health”. There is also a visible
opposition between the doctor’s knowledge and the lay people’s beliefs; while a doctor is
objective and positivist, a lay person is subjective and interpretivist; simultaneously, a doctor
focuses on science and quantity, while a lay person focuses on opinions and quality. It is no
longer a matter of who’s right or wrong, it comes to evidence versus narration. It is, indeed,
crucial to understand that these perspectives contribute to a better understanding of health, illness
and disease. It has been said that “Other voices matter” and [ CITATION Yui10 \l 1033 ] have
identified this feature of the social model, among others like having knowledge and perspectives
go beyond the biomedical approach or the fact that the quintessence of maintaining and
supporting health is understanding how people construct and interpret health and well-being.

To support this, there is no denying that first and foremost there must be an established
relationship between the specialist and the simple man. In this case, I shall refer to such a
connection as a doctor-patient relationship which usually encompasses the lay and professional
interaction in the course of a medical consultation. As stated by [ CITATION Gab04 \l 1033 ], these
encounters are influenced by the context of the consultation and the communication style (bear in
mind that it is the same principle as in the process of defining health). To further analyze this
concept, three main sociological models have been identified: consensus, conflict and
negotiation.

According to [ CITATION Par51 \l 1033 ], consensus entails bringing general social

expectations and obligations into the medical encounter. Therefore, a doctor is obligated to tick
the following boxes: performance (as in technical competence), affective neutrality (he/she
should not have any emotional attachment to the patient), appropriate universalism (he/she
should relate to the basis of general criteria and not particularly to the individual), specificity
(he/she should maintain a specific relationship for a specific purpose). On the other side, the
patient (i.e. the sick) should want to get well and should seek professional help with the
physician, as well as cooperate throughout the entire process. None of the parts involved in such
a relationship lacks rights: the doctor has the freedom from organizational or professional
constraints and is allowed access to tabooed areas of the patient’s body, while the patient has the
right to be exempt from normal social roles or responsibilities and has absolution from blame for
his or her illness.

The second sociological model is conflict and, according to [ CITATION Fre70 \l 1033 ], a
conflictual relationship is characterized by having the doctor and the patient in different social
worlds and positions. Furthermore, the doctor might not be willing to give as much information
as required by patients and handle cases with a “business-as-usual” attitude, which is unfair to
the patient. On the other side, the patient might consult with trivia or delay in help seeking and
even struggle with getting individual care, which is unfair to the doctor. Each of these
characteristics does not benefit the doctor-patient relationship in any way.

[ CITATION Kat81 \l 1033 ] consider that the third sociological model “is a transactional
model that suggests that the clinical encounter is a negotiation that takes place between two
kinds of knowledge (lay and professional)”. In this relationship, both parts are active and, even if
there is a conflict, the desire to work towards a solution is present. There might be situations
when the patient’s views are sometimes ignored and they might become difficult as they are not
treated as experts of their own body. Patients can be considered “bad patients” if they come
forward with medically unexplained symptoms, who are non-compliant and non-appreciative,
who consider themselves deserving of their illness or who become manipulative (which might be
the case when dealing with self-harm and mental health problems).

Any doctor-patient relationship includes medication in one form or another and,

therefore, we can discuss the following concepts: adherence, non-adherence and concordance.
[ CITATION Hor05 \l 1033 ] defines adherence as “the extent to which the patient’s behaviour
matches agreed recommendations from the prescriber”. In an attempt to highlight the fact that
the patient is free to decide whether to adhere to the doctor’s recommendations or not, the term
adherence has been adopted as an alternative to the term compliance. The failure to adhere to the
specialist’s recommendations leads to and is identified as non-adherence. Receiving a
prescription but not collecting the medication at the pharmacy, taking a different dose than the
one prescribed, taking medication at different times than prescribed or recommended, forgetting
one or more doses or, on the other hand, increasing the frequency of taking such doses and
stopping taking the medication before the prescribed length are actions that can be considered
manifestations of non-adherence.

Of course, there are many causes of non-adherence. some of which are the complexity of
the treatment regimen, socio-demographic characteristics, status and health literacy, lack of
social support, depression and anxiety, misconstrued beliefs about drugs and, nonetheless,
miscommunication and misunderstandings. One of the most striking examples to support this
behaviour is type 2 diabetes. Poor medication adherence in this case varies from 38% to 93%
[ CITATION Pol16 \l 1033 ] and the wide range is a result of different methodological approaches.
Factors contributing to this percentage are both intentional and unintentional. Some of the
intentional factors are the critical patient beliefs about their medications being perceived as
inefficient, dangerous or having too many side effects, modification of dosage and frequency due
to unrealistic expectations and, unfortunately, complete and utter rejection of a treatment
regimen. The unintentional factors include difficulties in using medication devices like insulin
pumps, glycemic sensors and test strips, lack of knowledge regarding the steps to be taken during
a treatment process or forgetfulness. Strategies and measures of improvement that target poor
adherence should focus on decreasing medication efforts and answering those questions that
usually have a negative reaction and response. In developing such strategies, interventions to
support adherence should be considered and the main final goal should be concordance. The
European Patient Forum[ CITATION Eur15 \l 1033 ] stated in 2015 that “health professionals should
move towards concordance and the respect for a patient’s “free and informed choice of
treatment” as the foundation for supporting patient adherence”. In order to achieve concordance
in the case of patients that suffer from type 2 diabetes, specialist should consider giving more
information, in more detail and without diminishing the patient’s capacity and ability of
understanding, should try to enhance capacity and motivate the patient to do small but significant
things such as track their medicine-taking, monitor their evolution and use a multi-compartment
medicine-taking system. If one of the issues that the patient has with the treatment is the fear of
side effects, the specialist should discuss the benefits and long-term effects that the medication
might have if it is taken as prescribed, should consider the possibility of switching to another
medicine with a different risk of side effects or brainstorm other strategies to be used instead of
said medication. Concordance is even more so achievable if the specialist understands and fully
acknowledges that there are no identical patients and the conversations, consultations, problems,
burdens, treatments and regimens should be tailored to fit each individual patient.

Conclusion
I began my discourse with the question Why do patients not adhere to treatments? After
having explained some key concepts, perspectives and approaches, I believe that the answer is
multi-faceted and complex. Patients do no adhere to treatments due to communication issues,
fear, lack of health literacy, material or financial impossibility, lack of support, mistrust,
miscommunication. There is a perpetual need for good healthcare systems, informed specialists,
people-oriented organizations, patience and, the most important need of all, humanity.
Works Cited

Anon., 2015. European Patient's Forum. [Online]

Available at: https://www.eu-patient.eu/
[Accessed 2018 January 2021].
Freidson, E., 1970. Sociological narratives of professionalism and medicine. In: The Palgrave Handbook
of Social Theory in Health. s.l.:s.n., pp. 287-305.
Gabe, M., 2004. A critical introduction to the risk society. Social Anthropology, 14(1), pp. 145-146.
Horne, R., 2005. Concordance, adherence and compliance In medicine taking. Report for the National
Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO). [Online]
Available at: : http://www.netscc.ac.uk/hsdr/files/project/SDO_FR_08-1412-076_V01.pdf
[Accessed 19 January 2021].
Huber, M. & al, e., 2011. How should we define health?. BMJ, Volume 343, pp. 235-7.
Katon, W. & Kleinman, A., 1981. Doctor-Patient Negotiation and Other Social Science Strategies in
Patient Care. In: Springer, ed. The Relevance of Social Science in Medicine. Culture, Illness and Healing.
Dordrecht: s.n., pp. 253-279.
Macfarlane, A. & D., K., 2002. Concepts of illness causation and attitudes to health care among older
people in the Republic of Ireland. Soc Sci Med, Issue 54, pp. 1389-400.
Nettleton, S., 2013. The Sociology of Health and Illness. 3rd ed. Cambridge: Polity Press.
NIH, n.d. The Human Genome Project. [Online]
Available at: https://www.genome.gov/human-genome-project
[Accessed 18 January 2021].
Parsons, T., 1951. Illness and the role of the physician: A sociological perspective. American Journal of
Orthopsychiatry, 21(3).
Polonsky, W. H. & Henry, R. R., 2016. Poor medication adherence in type 2 diabetes: recognizing the
scope of the problem and its key contributors. [Online]
Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4966497/
[Accessed 19 January 2021].
WHO, 1948. Preamble to the Constitution of WHO as adopted by the International Health Conference.
New York: s.n.
Yuill, C. & Duncan, E., 2010. Key Concepts in Health Studies. London: SAGE publications Ltd.